Oral-Systemic Links: Gestational Diabetes Mellitus, Periodontitis and Maternal/Fetal Outcomes Karen Novak, D.D.S., M.S., Ph.D. Professor, Department of Periodontics & Dental Hygiene Associate Dean for Professional Development & Faculty Affairs University of Texas Health Science Center School of Dentistry at Houston
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Oral-Systemic Links Gestational Diabetes Mellitus
Periodontitis and MaternalFetal Outcomes
Karen Novak DDS MS PhD
Professor Department of Periodontics amp Dental Hygiene Associate Dean for Professional Development amp Faculty Affairs
University of Texas Health Science Center School of Dentistry at Houston
Interprofessional Collaboration for Collective Impact
bull Dr Jeff Ebersole Basic Scientist
bull Dr James E Ferguson OBGYN
bull Dr John Novak Periodontist and Basic Scientist
bull Dr George Taylor General Dentist Epidemiologist
Objectives
bull After this presentation participants will be able to ndash discuss the etiology of gestational diabetes mellitus (GDM)
ndash describe how periodontal disease (PD) GDM and negative pregnancy outcomes may be linked
ndash describe data linking PD GDM and negative pregnancy outcomes
Gestational Diabetes Mellitus (GDM)
bull Diabetes that has onset during pregnancy
bull Occurs in approximately 5-7 of pregnant women
bull Is the most common metabolic disorder of pregnancy
GDM Etiology
bull Women with GDM make sufficient amounts of insulin ndash Placental hormones block the effect of insulin leading to
ldquoinsulin resistancerdquo
ndash The larger the placenta grows the more these hormones are produced and the greater the insulin resistance becomes
GDM Risk Factors
bull Obesity
bull Previous history of GDM
bull Family history of diabetes
bull Having given birth previously to a very large infant a still birth or a child with a birth defect
bull Having too much amniotic fluid
bull Being gt25 years of age
bull Being African American HispanicLatina American American Indian
ndash Positive (gt200 mgdL) bull Diagnostic no further test needed
GDM Testing and Diagnosis bull GTT
ndash Overnight fast followed by 100 gm glucose administration
ndash Fasting 1 2 and 3 hour plasma levels obtained
ndash Two values gt normal are diagnostic bull Fasting 105 mgdL
bull 1 hour 190 mgdL
bull 2 hours 165 mgdL
bull 3 hours 145 mgdL
GDM Testing and Diagnosis
bull Average risk women
ndash Tested between 24-28 weeks gestation
bull High risk women
ndash Tested as soon as possible
GDM Potential Negative Outcomes
bull After pregnancy 5-10 of women with GDM develop type 2 diabetes mellitus
bull Women who have had GDM have a 20-50 chance of developing type 2 diabetes in the next 5-10 years
Study 1 NHANES III Analysis
Novak KF Taylor G Ferguson JE and Novak MJ 2006 Periodontitis and Gestational Diabetes Mellitus Exploring the Link in NHANES III J Pub Health Dent 66163-168
Periodontal Disease and GDM bull 4244 women ages 20-59
ndash 113 had a history of GDM during pregnancy
bull Periodontal disease defined as one or more teeth with one or more sites with PDgt4mm LOA gt2mm and bleeding on probing
bull There was a trend for women with a history of GDM to have more periodontal disease than women without a history of GDM
Hypothesis Fig 1
Gestational Diabetes Mellitus Periodontal Disease
Negative Maternal and Fetal Outcomes
Combined Effect
Novak KF Taylor G Ferguson JE and Novak MJ 2006 Periodontitis and Gestational Diabetes Mellitus
Exploring the Link in NHANES III J Pub Health Dent 66163-168
Periodontal Disease and GDM bull Prior GDM higher pre-pregnancy BMI vaginal levels of Tannerella forsythia and C-
reactive protein were risk factors for developing GDM Periodontal disease was not statistically significant Dasanayakeet al 2008
ldquoNew Evidence of Periodontal Disease Leading to Gestational Diabetesrdquo
bull Further support for the hypothesis that there is an association between periodontal disease and GDM Xiong et al 2009
bull The presence of periodontal disease was significantly higher in women with either GDM or Type 2 diabetes during their pregnancy Age pregestational BMI and HbA1c) were related to clinical attachment loss in these two group Ruiz et al 2011
bull Women with both prior GDM and periodontal disease showed greater insulin resistance and altered Beta cell function potentially making them at greater risk for developing Type 2 diabetes Xiong et al 2012
Study 2 NIH Cross-Sectional Analysis
NIHNCRR Center of Biomedical Research Excellence P20 RR020145
University of Kentucky CR-DOC
Study Population
bull 306 matched pairs of pregnant women ndash Ages 16-45
ndash No history of type 1 or type 2 diabetes mellitus
ndash Minimum of 20 teeth
bull 153 with GDM 153 controls without GDM ndash Age raceethnicity and gestational age matched
bull Categorized by presenceabsence of periodontal disease (PD)
Data Collection bull Enrollment
ndash Consent and HIPAA authorization
ndash Medical and dental histories
ndash Comprehensive periodontal examination
bull Plaque index probing pocket depths clinical
attachment levels bleeding index calculus index
ndash Periodontitis (PD)
bull At least 4 teeth with PD gt4mm LOA gt2mm and
BOP
Data Collection
Laboratory samples
bull Serum ndash assessed by ELISA and Luminex
bull Subgingival plaque ndash biofilm microbiota assessed by qPCR
Data collection bull Post-delivery maternal and fetal outcomes
ndash Maternal pre-eclampsia premature labor premature rupture of membranes urinary tract infections chorioamnionitisfunisitis induction of labor operative vaginal deliveries or unplanned cesarean
Multivariable logistic regression GEE adjusted for smoking and calculus Variables used for matching were not used as covariates in the GEE matched analysis regression
modeling These included age raceethnicity and gestational age at enrollment
Conclusion bull Women in this study with the combination of GDM
plus periodontal disease had
ndash a 23-fold greater risk for developing adverse maternal outcomes than women with either GDM or periodontal disease alone
Fig 1
Gestational Diabetes Mellitus Periodontal Disease
Negative Maternal and Fetal Outcomes
Combined Effect
Periodontal Variable
Adverse pregnancy outcomes
n=130
No adverse pregnancy outcomes
n=176
P- value (Wilcoxon test)
Plaque index 056 (019) 053 (017) 008
Probing depth 28 (051) 27 (056) 001
Clinical attachment loss
063 (055) 062 (055) 084
Calculus (0-3) 044 (037) 039 (037) 017
Bleeding (0-3) 036 (030) 033 (031) 007
Case Control Comparison
Periodontal Variable
GDM + n=153
GDM ndash n=153
(P- value) (Wilcoxon
test)
Plaque index 055 (017) 053 (019) 026
Probing depth 28 (057) 27 (049) 008
Clinical attachment loss
066 (056) 058 (054) 021
Calculus (0-3) 044 (037) 039 (037) 020
Bleeding (0-3) 037 (031) 032 (030) 021
Case Control Comparison
Conclusions bull Probing pocket depth independent of GDM
status was a significant predictor of adverse pregnancy outcomes (p=001)
bull Bleeding on probing was related to adverse pregnancy outcomes (p=007)
bull GDM status was related to probing pocket depth (p=008)
Odds Ratios for Adverse Fetal Outcomes
Contrasts for PD and GDM status Odds Ratio 95 CI
PD+ GDM+ vs PD- GDM- 142 064 314
PD+ GDM+ vs PD- GDM+ 147 066 327
PD+ GDM+ vs PD+ GDM- 119 058 242
Multivariable logistic regression GEE adjusted for smoking and calculus Variables used for matching were not used as covariates in the GEE matched analysis regression
modeling These included age raceethnicity and gestational age at enrollment
Conclusion bull Women in this study with the combination of GDM
plus periodontal disease had
ndash no greater risk for adverse fetal outcomes than women with either GDM or periodontal disease alone
Conclusions bull Women in this study with the combination of GDM
plus periodontal disease had
ndash a 23-fold greater risk for developing adverse maternal outcomes than women with either GDM or periodontal disease alone bull Probing pocket depth independent of GDM status was a
significant predictor of adverse pregnancy outcomes (p=001)
bull Bleeding on probing was related to adverse pregnancy outcomes (p=007)
bull GDM status was related to probing pocket depth (p=008)
ndash no greater risk for adverse fetal outcomes than women with either GDM or periodontal disease alone
Exploring the possible biology of an oral-systemic link
ldquoOral health is integral to general healthrdquo
A ldquosilent epidemic of oral diseases is affecting our most vulnerable citizensrdquo
How could periodontal disease contribute to systemic
conditions
Defining periodontal disease
bull An inflammatory disease that is initiated by the
accumulation of Gram-negative bacteria around the
teeth and gums
Potential mechanisms
bull Dissemination of periodontal infection
bull Dissemination of periodontal inflammation
Is there evidence that periodontal bacteria play a major role
bull ldquoGuilt by associationrdquo
ndash Periodontal bacteria rarely found in systemic organs
ndash Case of fetal demise due to oral Fusobacterial infection extremely rare
ndash No cases of stroke or myocardial infarction due to periodontal infection
Letrsquos look at inflammation as a potential culprit
Inflammation
bull Initiates the host response to challenge
bull Brings immune cells and molecules to the site of challenge
bull A tightly regulated mechanism
bull When dysregulated leads to pathology
ndash Genetic (polymorphisms in gene structure)
ndash Environmental (smoking stress diet)
ndash Systemic (obesity type 2 diabetes hormonal)
Including
Periodontal disease
Periodontal disease and systemic disease
bull Risk indicator or risk factor
ndash Risk indicator ndash periodontal disease and the systemic condition share common etiologies
ndash Risk factor ndash oral infectioninflammation contributes to the genesis of the systemic condition Remove periodontal disease and the systemic condition improves
What is the evidence
bull Cross sectional studies
ndash periodontal disease may be a risk indicator for systemic inflammatory conditions in certain populations
ndash failed to show a causal effect suggesting that periodontal disease is not a risk factor for systemic disease
What is the answer
bull Periodontitis and systemic inflammatory conditions have complex etiologies
bull Influenced by
ndash Socio-economic status
ndash Lifestyle choicesbehaviors
bull Diet stress smoking drug abuse
ndash Genetics family history a good predictor
bull Infection
bull Inflammation
The answer may lie in complex interactions between multiple components of susceptibility This may make it very difficult to show a direct causal relationship between periodontal disease and systemic conditions
Thank you
KarenFNovakuthtmcedu
References Dasanayake AP1 Chhun N Tanner AC Craig RG Lee MJ Moore AF Norman RG J Dent Res 2008 Periodontal pathogens and gestational diabetes mellitus 2008 Apr87(4)328-33 Xiong X1 Elkind-Hirsch KE Vastardis S Delarosa RL Pridjian G Buekens P Periodontal disease is associated with gestational diabetes mellitus a case-control study J Periodontol 2009 Nov80(11)1742-9 Ruiz DR1 Romito GA Dib SA Periodontal disease in gestational and type 1 diabetes mellitus pregnant women Oral Dis 2011 Jul17(5)515-21 Xiong X Elkind-Hirsch KE Xie Y Delarosa R Maney P Pridjian G Buekens P Periodontal disease as a potential risk factor for the development of diabetes in women with a prior history of gestational diabetes mellitus J Public Health Dent 2013 Winter73(1)41-9 Michalowicz BS Hodges JS DiANgelis AJ Lupo VR Novak MJ Ferguson JE et al Treatment of periodontal disease and the risk of preterm birth N Engl J Med 2006 3551885-94 Offenbacher S Beck JD Jared HL Maaureilllo SM Mendoza LC Couper DJ et al Effects of periodontal therapy on rate or preterm delivery a randomized controlled trial Maternal Oral Therapy to Reduce Obstetric Risk (MOTOR) Investigators Obstet Gynecol 2009 114551-9 Committee on Health Care for Underserved Women Committee Opinion Oral health care during pregnancy and through the lifespan 2013 122417-422
Interprofessional Collaboration for Collective Impact
bull Dr Jeff Ebersole Basic Scientist
bull Dr James E Ferguson OBGYN
bull Dr John Novak Periodontist and Basic Scientist
bull Dr George Taylor General Dentist Epidemiologist
Objectives
bull After this presentation participants will be able to ndash discuss the etiology of gestational diabetes mellitus (GDM)
ndash describe how periodontal disease (PD) GDM and negative pregnancy outcomes may be linked
ndash describe data linking PD GDM and negative pregnancy outcomes
Gestational Diabetes Mellitus (GDM)
bull Diabetes that has onset during pregnancy
bull Occurs in approximately 5-7 of pregnant women
bull Is the most common metabolic disorder of pregnancy
GDM Etiology
bull Women with GDM make sufficient amounts of insulin ndash Placental hormones block the effect of insulin leading to
ldquoinsulin resistancerdquo
ndash The larger the placenta grows the more these hormones are produced and the greater the insulin resistance becomes
GDM Risk Factors
bull Obesity
bull Previous history of GDM
bull Family history of diabetes
bull Having given birth previously to a very large infant a still birth or a child with a birth defect
bull Having too much amniotic fluid
bull Being gt25 years of age
bull Being African American HispanicLatina American American Indian
ndash Positive (gt200 mgdL) bull Diagnostic no further test needed
GDM Testing and Diagnosis bull GTT
ndash Overnight fast followed by 100 gm glucose administration
ndash Fasting 1 2 and 3 hour plasma levels obtained
ndash Two values gt normal are diagnostic bull Fasting 105 mgdL
bull 1 hour 190 mgdL
bull 2 hours 165 mgdL
bull 3 hours 145 mgdL
GDM Testing and Diagnosis
bull Average risk women
ndash Tested between 24-28 weeks gestation
bull High risk women
ndash Tested as soon as possible
GDM Potential Negative Outcomes
bull After pregnancy 5-10 of women with GDM develop type 2 diabetes mellitus
bull Women who have had GDM have a 20-50 chance of developing type 2 diabetes in the next 5-10 years
Study 1 NHANES III Analysis
Novak KF Taylor G Ferguson JE and Novak MJ 2006 Periodontitis and Gestational Diabetes Mellitus Exploring the Link in NHANES III J Pub Health Dent 66163-168
Periodontal Disease and GDM bull 4244 women ages 20-59
ndash 113 had a history of GDM during pregnancy
bull Periodontal disease defined as one or more teeth with one or more sites with PDgt4mm LOA gt2mm and bleeding on probing
bull There was a trend for women with a history of GDM to have more periodontal disease than women without a history of GDM
Hypothesis Fig 1
Gestational Diabetes Mellitus Periodontal Disease
Negative Maternal and Fetal Outcomes
Combined Effect
Novak KF Taylor G Ferguson JE and Novak MJ 2006 Periodontitis and Gestational Diabetes Mellitus
Exploring the Link in NHANES III J Pub Health Dent 66163-168
Periodontal Disease and GDM bull Prior GDM higher pre-pregnancy BMI vaginal levels of Tannerella forsythia and C-
reactive protein were risk factors for developing GDM Periodontal disease was not statistically significant Dasanayakeet al 2008
ldquoNew Evidence of Periodontal Disease Leading to Gestational Diabetesrdquo
bull Further support for the hypothesis that there is an association between periodontal disease and GDM Xiong et al 2009
bull The presence of periodontal disease was significantly higher in women with either GDM or Type 2 diabetes during their pregnancy Age pregestational BMI and HbA1c) were related to clinical attachment loss in these two group Ruiz et al 2011
bull Women with both prior GDM and periodontal disease showed greater insulin resistance and altered Beta cell function potentially making them at greater risk for developing Type 2 diabetes Xiong et al 2012
Study 2 NIH Cross-Sectional Analysis
NIHNCRR Center of Biomedical Research Excellence P20 RR020145
University of Kentucky CR-DOC
Study Population
bull 306 matched pairs of pregnant women ndash Ages 16-45
ndash No history of type 1 or type 2 diabetes mellitus
ndash Minimum of 20 teeth
bull 153 with GDM 153 controls without GDM ndash Age raceethnicity and gestational age matched
bull Categorized by presenceabsence of periodontal disease (PD)
Data Collection bull Enrollment
ndash Consent and HIPAA authorization
ndash Medical and dental histories
ndash Comprehensive periodontal examination
bull Plaque index probing pocket depths clinical
attachment levels bleeding index calculus index
ndash Periodontitis (PD)
bull At least 4 teeth with PD gt4mm LOA gt2mm and
BOP
Data Collection
Laboratory samples
bull Serum ndash assessed by ELISA and Luminex
bull Subgingival plaque ndash biofilm microbiota assessed by qPCR
Data collection bull Post-delivery maternal and fetal outcomes
ndash Maternal pre-eclampsia premature labor premature rupture of membranes urinary tract infections chorioamnionitisfunisitis induction of labor operative vaginal deliveries or unplanned cesarean
Multivariable logistic regression GEE adjusted for smoking and calculus Variables used for matching were not used as covariates in the GEE matched analysis regression
modeling These included age raceethnicity and gestational age at enrollment
Conclusion bull Women in this study with the combination of GDM
plus periodontal disease had
ndash a 23-fold greater risk for developing adverse maternal outcomes than women with either GDM or periodontal disease alone
Fig 1
Gestational Diabetes Mellitus Periodontal Disease
Negative Maternal and Fetal Outcomes
Combined Effect
Periodontal Variable
Adverse pregnancy outcomes
n=130
No adverse pregnancy outcomes
n=176
P- value (Wilcoxon test)
Plaque index 056 (019) 053 (017) 008
Probing depth 28 (051) 27 (056) 001
Clinical attachment loss
063 (055) 062 (055) 084
Calculus (0-3) 044 (037) 039 (037) 017
Bleeding (0-3) 036 (030) 033 (031) 007
Case Control Comparison
Periodontal Variable
GDM + n=153
GDM ndash n=153
(P- value) (Wilcoxon
test)
Plaque index 055 (017) 053 (019) 026
Probing depth 28 (057) 27 (049) 008
Clinical attachment loss
066 (056) 058 (054) 021
Calculus (0-3) 044 (037) 039 (037) 020
Bleeding (0-3) 037 (031) 032 (030) 021
Case Control Comparison
Conclusions bull Probing pocket depth independent of GDM
status was a significant predictor of adverse pregnancy outcomes (p=001)
bull Bleeding on probing was related to adverse pregnancy outcomes (p=007)
bull GDM status was related to probing pocket depth (p=008)
Odds Ratios for Adverse Fetal Outcomes
Contrasts for PD and GDM status Odds Ratio 95 CI
PD+ GDM+ vs PD- GDM- 142 064 314
PD+ GDM+ vs PD- GDM+ 147 066 327
PD+ GDM+ vs PD+ GDM- 119 058 242
Multivariable logistic regression GEE adjusted for smoking and calculus Variables used for matching were not used as covariates in the GEE matched analysis regression
modeling These included age raceethnicity and gestational age at enrollment
Conclusion bull Women in this study with the combination of GDM
plus periodontal disease had
ndash no greater risk for adverse fetal outcomes than women with either GDM or periodontal disease alone
Conclusions bull Women in this study with the combination of GDM
plus periodontal disease had
ndash a 23-fold greater risk for developing adverse maternal outcomes than women with either GDM or periodontal disease alone bull Probing pocket depth independent of GDM status was a
significant predictor of adverse pregnancy outcomes (p=001)
bull Bleeding on probing was related to adverse pregnancy outcomes (p=007)
bull GDM status was related to probing pocket depth (p=008)
ndash no greater risk for adverse fetal outcomes than women with either GDM or periodontal disease alone
Exploring the possible biology of an oral-systemic link
ldquoOral health is integral to general healthrdquo
A ldquosilent epidemic of oral diseases is affecting our most vulnerable citizensrdquo
How could periodontal disease contribute to systemic
conditions
Defining periodontal disease
bull An inflammatory disease that is initiated by the
accumulation of Gram-negative bacteria around the
teeth and gums
Potential mechanisms
bull Dissemination of periodontal infection
bull Dissemination of periodontal inflammation
Is there evidence that periodontal bacteria play a major role
bull ldquoGuilt by associationrdquo
ndash Periodontal bacteria rarely found in systemic organs
ndash Case of fetal demise due to oral Fusobacterial infection extremely rare
ndash No cases of stroke or myocardial infarction due to periodontal infection
Letrsquos look at inflammation as a potential culprit
Inflammation
bull Initiates the host response to challenge
bull Brings immune cells and molecules to the site of challenge
bull A tightly regulated mechanism
bull When dysregulated leads to pathology
ndash Genetic (polymorphisms in gene structure)
ndash Environmental (smoking stress diet)
ndash Systemic (obesity type 2 diabetes hormonal)
Including
Periodontal disease
Periodontal disease and systemic disease
bull Risk indicator or risk factor
ndash Risk indicator ndash periodontal disease and the systemic condition share common etiologies
ndash Risk factor ndash oral infectioninflammation contributes to the genesis of the systemic condition Remove periodontal disease and the systemic condition improves
What is the evidence
bull Cross sectional studies
ndash periodontal disease may be a risk indicator for systemic inflammatory conditions in certain populations
ndash failed to show a causal effect suggesting that periodontal disease is not a risk factor for systemic disease
What is the answer
bull Periodontitis and systemic inflammatory conditions have complex etiologies
bull Influenced by
ndash Socio-economic status
ndash Lifestyle choicesbehaviors
bull Diet stress smoking drug abuse
ndash Genetics family history a good predictor
bull Infection
bull Inflammation
The answer may lie in complex interactions between multiple components of susceptibility This may make it very difficult to show a direct causal relationship between periodontal disease and systemic conditions
Thank you
KarenFNovakuthtmcedu
References Dasanayake AP1 Chhun N Tanner AC Craig RG Lee MJ Moore AF Norman RG J Dent Res 2008 Periodontal pathogens and gestational diabetes mellitus 2008 Apr87(4)328-33 Xiong X1 Elkind-Hirsch KE Vastardis S Delarosa RL Pridjian G Buekens P Periodontal disease is associated with gestational diabetes mellitus a case-control study J Periodontol 2009 Nov80(11)1742-9 Ruiz DR1 Romito GA Dib SA Periodontal disease in gestational and type 1 diabetes mellitus pregnant women Oral Dis 2011 Jul17(5)515-21 Xiong X Elkind-Hirsch KE Xie Y Delarosa R Maney P Pridjian G Buekens P Periodontal disease as a potential risk factor for the development of diabetes in women with a prior history of gestational diabetes mellitus J Public Health Dent 2013 Winter73(1)41-9 Michalowicz BS Hodges JS DiANgelis AJ Lupo VR Novak MJ Ferguson JE et al Treatment of periodontal disease and the risk of preterm birth N Engl J Med 2006 3551885-94 Offenbacher S Beck JD Jared HL Maaureilllo SM Mendoza LC Couper DJ et al Effects of periodontal therapy on rate or preterm delivery a randomized controlled trial Maternal Oral Therapy to Reduce Obstetric Risk (MOTOR) Investigators Obstet Gynecol 2009 114551-9 Committee on Health Care for Underserved Women Committee Opinion Oral health care during pregnancy and through the lifespan 2013 122417-422
Objectives
bull After this presentation participants will be able to ndash discuss the etiology of gestational diabetes mellitus (GDM)
ndash describe how periodontal disease (PD) GDM and negative pregnancy outcomes may be linked
ndash describe data linking PD GDM and negative pregnancy outcomes
Gestational Diabetes Mellitus (GDM)
bull Diabetes that has onset during pregnancy
bull Occurs in approximately 5-7 of pregnant women
bull Is the most common metabolic disorder of pregnancy
GDM Etiology
bull Women with GDM make sufficient amounts of insulin ndash Placental hormones block the effect of insulin leading to
ldquoinsulin resistancerdquo
ndash The larger the placenta grows the more these hormones are produced and the greater the insulin resistance becomes
GDM Risk Factors
bull Obesity
bull Previous history of GDM
bull Family history of diabetes
bull Having given birth previously to a very large infant a still birth or a child with a birth defect
bull Having too much amniotic fluid
bull Being gt25 years of age
bull Being African American HispanicLatina American American Indian
ndash Positive (gt200 mgdL) bull Diagnostic no further test needed
GDM Testing and Diagnosis bull GTT
ndash Overnight fast followed by 100 gm glucose administration
ndash Fasting 1 2 and 3 hour plasma levels obtained
ndash Two values gt normal are diagnostic bull Fasting 105 mgdL
bull 1 hour 190 mgdL
bull 2 hours 165 mgdL
bull 3 hours 145 mgdL
GDM Testing and Diagnosis
bull Average risk women
ndash Tested between 24-28 weeks gestation
bull High risk women
ndash Tested as soon as possible
GDM Potential Negative Outcomes
bull After pregnancy 5-10 of women with GDM develop type 2 diabetes mellitus
bull Women who have had GDM have a 20-50 chance of developing type 2 diabetes in the next 5-10 years
Study 1 NHANES III Analysis
Novak KF Taylor G Ferguson JE and Novak MJ 2006 Periodontitis and Gestational Diabetes Mellitus Exploring the Link in NHANES III J Pub Health Dent 66163-168
Periodontal Disease and GDM bull 4244 women ages 20-59
ndash 113 had a history of GDM during pregnancy
bull Periodontal disease defined as one or more teeth with one or more sites with PDgt4mm LOA gt2mm and bleeding on probing
bull There was a trend for women with a history of GDM to have more periodontal disease than women without a history of GDM
Hypothesis Fig 1
Gestational Diabetes Mellitus Periodontal Disease
Negative Maternal and Fetal Outcomes
Combined Effect
Novak KF Taylor G Ferguson JE and Novak MJ 2006 Periodontitis and Gestational Diabetes Mellitus
Exploring the Link in NHANES III J Pub Health Dent 66163-168
Periodontal Disease and GDM bull Prior GDM higher pre-pregnancy BMI vaginal levels of Tannerella forsythia and C-
reactive protein were risk factors for developing GDM Periodontal disease was not statistically significant Dasanayakeet al 2008
ldquoNew Evidence of Periodontal Disease Leading to Gestational Diabetesrdquo
bull Further support for the hypothesis that there is an association between periodontal disease and GDM Xiong et al 2009
bull The presence of periodontal disease was significantly higher in women with either GDM or Type 2 diabetes during their pregnancy Age pregestational BMI and HbA1c) were related to clinical attachment loss in these two group Ruiz et al 2011
bull Women with both prior GDM and periodontal disease showed greater insulin resistance and altered Beta cell function potentially making them at greater risk for developing Type 2 diabetes Xiong et al 2012
Study 2 NIH Cross-Sectional Analysis
NIHNCRR Center of Biomedical Research Excellence P20 RR020145
University of Kentucky CR-DOC
Study Population
bull 306 matched pairs of pregnant women ndash Ages 16-45
ndash No history of type 1 or type 2 diabetes mellitus
ndash Minimum of 20 teeth
bull 153 with GDM 153 controls without GDM ndash Age raceethnicity and gestational age matched
bull Categorized by presenceabsence of periodontal disease (PD)
Data Collection bull Enrollment
ndash Consent and HIPAA authorization
ndash Medical and dental histories
ndash Comprehensive periodontal examination
bull Plaque index probing pocket depths clinical
attachment levels bleeding index calculus index
ndash Periodontitis (PD)
bull At least 4 teeth with PD gt4mm LOA gt2mm and
BOP
Data Collection
Laboratory samples
bull Serum ndash assessed by ELISA and Luminex
bull Subgingival plaque ndash biofilm microbiota assessed by qPCR
Data collection bull Post-delivery maternal and fetal outcomes
ndash Maternal pre-eclampsia premature labor premature rupture of membranes urinary tract infections chorioamnionitisfunisitis induction of labor operative vaginal deliveries or unplanned cesarean
Multivariable logistic regression GEE adjusted for smoking and calculus Variables used for matching were not used as covariates in the GEE matched analysis regression
modeling These included age raceethnicity and gestational age at enrollment
Conclusion bull Women in this study with the combination of GDM
plus periodontal disease had
ndash a 23-fold greater risk for developing adverse maternal outcomes than women with either GDM or periodontal disease alone
Fig 1
Gestational Diabetes Mellitus Periodontal Disease
Negative Maternal and Fetal Outcomes
Combined Effect
Periodontal Variable
Adverse pregnancy outcomes
n=130
No adverse pregnancy outcomes
n=176
P- value (Wilcoxon test)
Plaque index 056 (019) 053 (017) 008
Probing depth 28 (051) 27 (056) 001
Clinical attachment loss
063 (055) 062 (055) 084
Calculus (0-3) 044 (037) 039 (037) 017
Bleeding (0-3) 036 (030) 033 (031) 007
Case Control Comparison
Periodontal Variable
GDM + n=153
GDM ndash n=153
(P- value) (Wilcoxon
test)
Plaque index 055 (017) 053 (019) 026
Probing depth 28 (057) 27 (049) 008
Clinical attachment loss
066 (056) 058 (054) 021
Calculus (0-3) 044 (037) 039 (037) 020
Bleeding (0-3) 037 (031) 032 (030) 021
Case Control Comparison
Conclusions bull Probing pocket depth independent of GDM
status was a significant predictor of adverse pregnancy outcomes (p=001)
bull Bleeding on probing was related to adverse pregnancy outcomes (p=007)
bull GDM status was related to probing pocket depth (p=008)
Odds Ratios for Adverse Fetal Outcomes
Contrasts for PD and GDM status Odds Ratio 95 CI
PD+ GDM+ vs PD- GDM- 142 064 314
PD+ GDM+ vs PD- GDM+ 147 066 327
PD+ GDM+ vs PD+ GDM- 119 058 242
Multivariable logistic regression GEE adjusted for smoking and calculus Variables used for matching were not used as covariates in the GEE matched analysis regression
modeling These included age raceethnicity and gestational age at enrollment
Conclusion bull Women in this study with the combination of GDM
plus periodontal disease had
ndash no greater risk for adverse fetal outcomes than women with either GDM or periodontal disease alone
Conclusions bull Women in this study with the combination of GDM
plus periodontal disease had
ndash a 23-fold greater risk for developing adverse maternal outcomes than women with either GDM or periodontal disease alone bull Probing pocket depth independent of GDM status was a
significant predictor of adverse pregnancy outcomes (p=001)
bull Bleeding on probing was related to adverse pregnancy outcomes (p=007)
bull GDM status was related to probing pocket depth (p=008)
ndash no greater risk for adverse fetal outcomes than women with either GDM or periodontal disease alone
Exploring the possible biology of an oral-systemic link
ldquoOral health is integral to general healthrdquo
A ldquosilent epidemic of oral diseases is affecting our most vulnerable citizensrdquo
How could periodontal disease contribute to systemic
conditions
Defining periodontal disease
bull An inflammatory disease that is initiated by the
accumulation of Gram-negative bacteria around the
teeth and gums
Potential mechanisms
bull Dissemination of periodontal infection
bull Dissemination of periodontal inflammation
Is there evidence that periodontal bacteria play a major role
bull ldquoGuilt by associationrdquo
ndash Periodontal bacteria rarely found in systemic organs
ndash Case of fetal demise due to oral Fusobacterial infection extremely rare
ndash No cases of stroke or myocardial infarction due to periodontal infection
Letrsquos look at inflammation as a potential culprit
Inflammation
bull Initiates the host response to challenge
bull Brings immune cells and molecules to the site of challenge
bull A tightly regulated mechanism
bull When dysregulated leads to pathology
ndash Genetic (polymorphisms in gene structure)
ndash Environmental (smoking stress diet)
ndash Systemic (obesity type 2 diabetes hormonal)
Including
Periodontal disease
Periodontal disease and systemic disease
bull Risk indicator or risk factor
ndash Risk indicator ndash periodontal disease and the systemic condition share common etiologies
ndash Risk factor ndash oral infectioninflammation contributes to the genesis of the systemic condition Remove periodontal disease and the systemic condition improves
What is the evidence
bull Cross sectional studies
ndash periodontal disease may be a risk indicator for systemic inflammatory conditions in certain populations
ndash failed to show a causal effect suggesting that periodontal disease is not a risk factor for systemic disease
What is the answer
bull Periodontitis and systemic inflammatory conditions have complex etiologies
bull Influenced by
ndash Socio-economic status
ndash Lifestyle choicesbehaviors
bull Diet stress smoking drug abuse
ndash Genetics family history a good predictor
bull Infection
bull Inflammation
The answer may lie in complex interactions between multiple components of susceptibility This may make it very difficult to show a direct causal relationship between periodontal disease and systemic conditions
Thank you
KarenFNovakuthtmcedu
References Dasanayake AP1 Chhun N Tanner AC Craig RG Lee MJ Moore AF Norman RG J Dent Res 2008 Periodontal pathogens and gestational diabetes mellitus 2008 Apr87(4)328-33 Xiong X1 Elkind-Hirsch KE Vastardis S Delarosa RL Pridjian G Buekens P Periodontal disease is associated with gestational diabetes mellitus a case-control study J Periodontol 2009 Nov80(11)1742-9 Ruiz DR1 Romito GA Dib SA Periodontal disease in gestational and type 1 diabetes mellitus pregnant women Oral Dis 2011 Jul17(5)515-21 Xiong X Elkind-Hirsch KE Xie Y Delarosa R Maney P Pridjian G Buekens P Periodontal disease as a potential risk factor for the development of diabetes in women with a prior history of gestational diabetes mellitus J Public Health Dent 2013 Winter73(1)41-9 Michalowicz BS Hodges JS DiANgelis AJ Lupo VR Novak MJ Ferguson JE et al Treatment of periodontal disease and the risk of preterm birth N Engl J Med 2006 3551885-94 Offenbacher S Beck JD Jared HL Maaureilllo SM Mendoza LC Couper DJ et al Effects of periodontal therapy on rate or preterm delivery a randomized controlled trial Maternal Oral Therapy to Reduce Obstetric Risk (MOTOR) Investigators Obstet Gynecol 2009 114551-9 Committee on Health Care for Underserved Women Committee Opinion Oral health care during pregnancy and through the lifespan 2013 122417-422
Gestational Diabetes Mellitus (GDM)
bull Diabetes that has onset during pregnancy
bull Occurs in approximately 5-7 of pregnant women
bull Is the most common metabolic disorder of pregnancy
GDM Etiology
bull Women with GDM make sufficient amounts of insulin ndash Placental hormones block the effect of insulin leading to
ldquoinsulin resistancerdquo
ndash The larger the placenta grows the more these hormones are produced and the greater the insulin resistance becomes
GDM Risk Factors
bull Obesity
bull Previous history of GDM
bull Family history of diabetes
bull Having given birth previously to a very large infant a still birth or a child with a birth defect
bull Having too much amniotic fluid
bull Being gt25 years of age
bull Being African American HispanicLatina American American Indian
ndash Positive (gt200 mgdL) bull Diagnostic no further test needed
GDM Testing and Diagnosis bull GTT
ndash Overnight fast followed by 100 gm glucose administration
ndash Fasting 1 2 and 3 hour plasma levels obtained
ndash Two values gt normal are diagnostic bull Fasting 105 mgdL
bull 1 hour 190 mgdL
bull 2 hours 165 mgdL
bull 3 hours 145 mgdL
GDM Testing and Diagnosis
bull Average risk women
ndash Tested between 24-28 weeks gestation
bull High risk women
ndash Tested as soon as possible
GDM Potential Negative Outcomes
bull After pregnancy 5-10 of women with GDM develop type 2 diabetes mellitus
bull Women who have had GDM have a 20-50 chance of developing type 2 diabetes in the next 5-10 years
Study 1 NHANES III Analysis
Novak KF Taylor G Ferguson JE and Novak MJ 2006 Periodontitis and Gestational Diabetes Mellitus Exploring the Link in NHANES III J Pub Health Dent 66163-168
Periodontal Disease and GDM bull 4244 women ages 20-59
ndash 113 had a history of GDM during pregnancy
bull Periodontal disease defined as one or more teeth with one or more sites with PDgt4mm LOA gt2mm and bleeding on probing
bull There was a trend for women with a history of GDM to have more periodontal disease than women without a history of GDM
Hypothesis Fig 1
Gestational Diabetes Mellitus Periodontal Disease
Negative Maternal and Fetal Outcomes
Combined Effect
Novak KF Taylor G Ferguson JE and Novak MJ 2006 Periodontitis and Gestational Diabetes Mellitus
Exploring the Link in NHANES III J Pub Health Dent 66163-168
Periodontal Disease and GDM bull Prior GDM higher pre-pregnancy BMI vaginal levels of Tannerella forsythia and C-
reactive protein were risk factors for developing GDM Periodontal disease was not statistically significant Dasanayakeet al 2008
ldquoNew Evidence of Periodontal Disease Leading to Gestational Diabetesrdquo
bull Further support for the hypothesis that there is an association between periodontal disease and GDM Xiong et al 2009
bull The presence of periodontal disease was significantly higher in women with either GDM or Type 2 diabetes during their pregnancy Age pregestational BMI and HbA1c) were related to clinical attachment loss in these two group Ruiz et al 2011
bull Women with both prior GDM and periodontal disease showed greater insulin resistance and altered Beta cell function potentially making them at greater risk for developing Type 2 diabetes Xiong et al 2012
Study 2 NIH Cross-Sectional Analysis
NIHNCRR Center of Biomedical Research Excellence P20 RR020145
University of Kentucky CR-DOC
Study Population
bull 306 matched pairs of pregnant women ndash Ages 16-45
ndash No history of type 1 or type 2 diabetes mellitus
ndash Minimum of 20 teeth
bull 153 with GDM 153 controls without GDM ndash Age raceethnicity and gestational age matched
bull Categorized by presenceabsence of periodontal disease (PD)
Data Collection bull Enrollment
ndash Consent and HIPAA authorization
ndash Medical and dental histories
ndash Comprehensive periodontal examination
bull Plaque index probing pocket depths clinical
attachment levels bleeding index calculus index
ndash Periodontitis (PD)
bull At least 4 teeth with PD gt4mm LOA gt2mm and
BOP
Data Collection
Laboratory samples
bull Serum ndash assessed by ELISA and Luminex
bull Subgingival plaque ndash biofilm microbiota assessed by qPCR
Data collection bull Post-delivery maternal and fetal outcomes
ndash Maternal pre-eclampsia premature labor premature rupture of membranes urinary tract infections chorioamnionitisfunisitis induction of labor operative vaginal deliveries or unplanned cesarean
Multivariable logistic regression GEE adjusted for smoking and calculus Variables used for matching were not used as covariates in the GEE matched analysis regression
modeling These included age raceethnicity and gestational age at enrollment
Conclusion bull Women in this study with the combination of GDM
plus periodontal disease had
ndash a 23-fold greater risk for developing adverse maternal outcomes than women with either GDM or periodontal disease alone
Fig 1
Gestational Diabetes Mellitus Periodontal Disease
Negative Maternal and Fetal Outcomes
Combined Effect
Periodontal Variable
Adverse pregnancy outcomes
n=130
No adverse pregnancy outcomes
n=176
P- value (Wilcoxon test)
Plaque index 056 (019) 053 (017) 008
Probing depth 28 (051) 27 (056) 001
Clinical attachment loss
063 (055) 062 (055) 084
Calculus (0-3) 044 (037) 039 (037) 017
Bleeding (0-3) 036 (030) 033 (031) 007
Case Control Comparison
Periodontal Variable
GDM + n=153
GDM ndash n=153
(P- value) (Wilcoxon
test)
Plaque index 055 (017) 053 (019) 026
Probing depth 28 (057) 27 (049) 008
Clinical attachment loss
066 (056) 058 (054) 021
Calculus (0-3) 044 (037) 039 (037) 020
Bleeding (0-3) 037 (031) 032 (030) 021
Case Control Comparison
Conclusions bull Probing pocket depth independent of GDM
status was a significant predictor of adverse pregnancy outcomes (p=001)
bull Bleeding on probing was related to adverse pregnancy outcomes (p=007)
bull GDM status was related to probing pocket depth (p=008)
Odds Ratios for Adverse Fetal Outcomes
Contrasts for PD and GDM status Odds Ratio 95 CI
PD+ GDM+ vs PD- GDM- 142 064 314
PD+ GDM+ vs PD- GDM+ 147 066 327
PD+ GDM+ vs PD+ GDM- 119 058 242
Multivariable logistic regression GEE adjusted for smoking and calculus Variables used for matching were not used as covariates in the GEE matched analysis regression
modeling These included age raceethnicity and gestational age at enrollment
Conclusion bull Women in this study with the combination of GDM
plus periodontal disease had
ndash no greater risk for adverse fetal outcomes than women with either GDM or periodontal disease alone
Conclusions bull Women in this study with the combination of GDM
plus periodontal disease had
ndash a 23-fold greater risk for developing adverse maternal outcomes than women with either GDM or periodontal disease alone bull Probing pocket depth independent of GDM status was a
significant predictor of adverse pregnancy outcomes (p=001)
bull Bleeding on probing was related to adverse pregnancy outcomes (p=007)
bull GDM status was related to probing pocket depth (p=008)
ndash no greater risk for adverse fetal outcomes than women with either GDM or periodontal disease alone
Exploring the possible biology of an oral-systemic link
ldquoOral health is integral to general healthrdquo
A ldquosilent epidemic of oral diseases is affecting our most vulnerable citizensrdquo
How could periodontal disease contribute to systemic
conditions
Defining periodontal disease
bull An inflammatory disease that is initiated by the
accumulation of Gram-negative bacteria around the
teeth and gums
Potential mechanisms
bull Dissemination of periodontal infection
bull Dissemination of periodontal inflammation
Is there evidence that periodontal bacteria play a major role
bull ldquoGuilt by associationrdquo
ndash Periodontal bacteria rarely found in systemic organs
ndash Case of fetal demise due to oral Fusobacterial infection extremely rare
ndash No cases of stroke or myocardial infarction due to periodontal infection
Letrsquos look at inflammation as a potential culprit
Inflammation
bull Initiates the host response to challenge
bull Brings immune cells and molecules to the site of challenge
bull A tightly regulated mechanism
bull When dysregulated leads to pathology
ndash Genetic (polymorphisms in gene structure)
ndash Environmental (smoking stress diet)
ndash Systemic (obesity type 2 diabetes hormonal)
Including
Periodontal disease
Periodontal disease and systemic disease
bull Risk indicator or risk factor
ndash Risk indicator ndash periodontal disease and the systemic condition share common etiologies
ndash Risk factor ndash oral infectioninflammation contributes to the genesis of the systemic condition Remove periodontal disease and the systemic condition improves
What is the evidence
bull Cross sectional studies
ndash periodontal disease may be a risk indicator for systemic inflammatory conditions in certain populations
ndash failed to show a causal effect suggesting that periodontal disease is not a risk factor for systemic disease
What is the answer
bull Periodontitis and systemic inflammatory conditions have complex etiologies
bull Influenced by
ndash Socio-economic status
ndash Lifestyle choicesbehaviors
bull Diet stress smoking drug abuse
ndash Genetics family history a good predictor
bull Infection
bull Inflammation
The answer may lie in complex interactions between multiple components of susceptibility This may make it very difficult to show a direct causal relationship between periodontal disease and systemic conditions
Thank you
KarenFNovakuthtmcedu
References Dasanayake AP1 Chhun N Tanner AC Craig RG Lee MJ Moore AF Norman RG J Dent Res 2008 Periodontal pathogens and gestational diabetes mellitus 2008 Apr87(4)328-33 Xiong X1 Elkind-Hirsch KE Vastardis S Delarosa RL Pridjian G Buekens P Periodontal disease is associated with gestational diabetes mellitus a case-control study J Periodontol 2009 Nov80(11)1742-9 Ruiz DR1 Romito GA Dib SA Periodontal disease in gestational and type 1 diabetes mellitus pregnant women Oral Dis 2011 Jul17(5)515-21 Xiong X Elkind-Hirsch KE Xie Y Delarosa R Maney P Pridjian G Buekens P Periodontal disease as a potential risk factor for the development of diabetes in women with a prior history of gestational diabetes mellitus J Public Health Dent 2013 Winter73(1)41-9 Michalowicz BS Hodges JS DiANgelis AJ Lupo VR Novak MJ Ferguson JE et al Treatment of periodontal disease and the risk of preterm birth N Engl J Med 2006 3551885-94 Offenbacher S Beck JD Jared HL Maaureilllo SM Mendoza LC Couper DJ et al Effects of periodontal therapy on rate or preterm delivery a randomized controlled trial Maternal Oral Therapy to Reduce Obstetric Risk (MOTOR) Investigators Obstet Gynecol 2009 114551-9 Committee on Health Care for Underserved Women Committee Opinion Oral health care during pregnancy and through the lifespan 2013 122417-422
GDM Etiology
bull Women with GDM make sufficient amounts of insulin ndash Placental hormones block the effect of insulin leading to
ldquoinsulin resistancerdquo
ndash The larger the placenta grows the more these hormones are produced and the greater the insulin resistance becomes
GDM Risk Factors
bull Obesity
bull Previous history of GDM
bull Family history of diabetes
bull Having given birth previously to a very large infant a still birth or a child with a birth defect
bull Having too much amniotic fluid
bull Being gt25 years of age
bull Being African American HispanicLatina American American Indian
ndash Positive (gt200 mgdL) bull Diagnostic no further test needed
GDM Testing and Diagnosis bull GTT
ndash Overnight fast followed by 100 gm glucose administration
ndash Fasting 1 2 and 3 hour plasma levels obtained
ndash Two values gt normal are diagnostic bull Fasting 105 mgdL
bull 1 hour 190 mgdL
bull 2 hours 165 mgdL
bull 3 hours 145 mgdL
GDM Testing and Diagnosis
bull Average risk women
ndash Tested between 24-28 weeks gestation
bull High risk women
ndash Tested as soon as possible
GDM Potential Negative Outcomes
bull After pregnancy 5-10 of women with GDM develop type 2 diabetes mellitus
bull Women who have had GDM have a 20-50 chance of developing type 2 diabetes in the next 5-10 years
Study 1 NHANES III Analysis
Novak KF Taylor G Ferguson JE and Novak MJ 2006 Periodontitis and Gestational Diabetes Mellitus Exploring the Link in NHANES III J Pub Health Dent 66163-168
Periodontal Disease and GDM bull 4244 women ages 20-59
ndash 113 had a history of GDM during pregnancy
bull Periodontal disease defined as one or more teeth with one or more sites with PDgt4mm LOA gt2mm and bleeding on probing
bull There was a trend for women with a history of GDM to have more periodontal disease than women without a history of GDM
Hypothesis Fig 1
Gestational Diabetes Mellitus Periodontal Disease
Negative Maternal and Fetal Outcomes
Combined Effect
Novak KF Taylor G Ferguson JE and Novak MJ 2006 Periodontitis and Gestational Diabetes Mellitus
Exploring the Link in NHANES III J Pub Health Dent 66163-168
Periodontal Disease and GDM bull Prior GDM higher pre-pregnancy BMI vaginal levels of Tannerella forsythia and C-
reactive protein were risk factors for developing GDM Periodontal disease was not statistically significant Dasanayakeet al 2008
ldquoNew Evidence of Periodontal Disease Leading to Gestational Diabetesrdquo
bull Further support for the hypothesis that there is an association between periodontal disease and GDM Xiong et al 2009
bull The presence of periodontal disease was significantly higher in women with either GDM or Type 2 diabetes during their pregnancy Age pregestational BMI and HbA1c) were related to clinical attachment loss in these two group Ruiz et al 2011
bull Women with both prior GDM and periodontal disease showed greater insulin resistance and altered Beta cell function potentially making them at greater risk for developing Type 2 diabetes Xiong et al 2012
Study 2 NIH Cross-Sectional Analysis
NIHNCRR Center of Biomedical Research Excellence P20 RR020145
University of Kentucky CR-DOC
Study Population
bull 306 matched pairs of pregnant women ndash Ages 16-45
ndash No history of type 1 or type 2 diabetes mellitus
ndash Minimum of 20 teeth
bull 153 with GDM 153 controls without GDM ndash Age raceethnicity and gestational age matched
bull Categorized by presenceabsence of periodontal disease (PD)
Data Collection bull Enrollment
ndash Consent and HIPAA authorization
ndash Medical and dental histories
ndash Comprehensive periodontal examination
bull Plaque index probing pocket depths clinical
attachment levels bleeding index calculus index
ndash Periodontitis (PD)
bull At least 4 teeth with PD gt4mm LOA gt2mm and
BOP
Data Collection
Laboratory samples
bull Serum ndash assessed by ELISA and Luminex
bull Subgingival plaque ndash biofilm microbiota assessed by qPCR
Data collection bull Post-delivery maternal and fetal outcomes
ndash Maternal pre-eclampsia premature labor premature rupture of membranes urinary tract infections chorioamnionitisfunisitis induction of labor operative vaginal deliveries or unplanned cesarean
Multivariable logistic regression GEE adjusted for smoking and calculus Variables used for matching were not used as covariates in the GEE matched analysis regression
modeling These included age raceethnicity and gestational age at enrollment
Conclusion bull Women in this study with the combination of GDM
plus periodontal disease had
ndash a 23-fold greater risk for developing adverse maternal outcomes than women with either GDM or periodontal disease alone
Fig 1
Gestational Diabetes Mellitus Periodontal Disease
Negative Maternal and Fetal Outcomes
Combined Effect
Periodontal Variable
Adverse pregnancy outcomes
n=130
No adverse pregnancy outcomes
n=176
P- value (Wilcoxon test)
Plaque index 056 (019) 053 (017) 008
Probing depth 28 (051) 27 (056) 001
Clinical attachment loss
063 (055) 062 (055) 084
Calculus (0-3) 044 (037) 039 (037) 017
Bleeding (0-3) 036 (030) 033 (031) 007
Case Control Comparison
Periodontal Variable
GDM + n=153
GDM ndash n=153
(P- value) (Wilcoxon
test)
Plaque index 055 (017) 053 (019) 026
Probing depth 28 (057) 27 (049) 008
Clinical attachment loss
066 (056) 058 (054) 021
Calculus (0-3) 044 (037) 039 (037) 020
Bleeding (0-3) 037 (031) 032 (030) 021
Case Control Comparison
Conclusions bull Probing pocket depth independent of GDM
status was a significant predictor of adverse pregnancy outcomes (p=001)
bull Bleeding on probing was related to adverse pregnancy outcomes (p=007)
bull GDM status was related to probing pocket depth (p=008)
Odds Ratios for Adverse Fetal Outcomes
Contrasts for PD and GDM status Odds Ratio 95 CI
PD+ GDM+ vs PD- GDM- 142 064 314
PD+ GDM+ vs PD- GDM+ 147 066 327
PD+ GDM+ vs PD+ GDM- 119 058 242
Multivariable logistic regression GEE adjusted for smoking and calculus Variables used for matching were not used as covariates in the GEE matched analysis regression
modeling These included age raceethnicity and gestational age at enrollment
Conclusion bull Women in this study with the combination of GDM
plus periodontal disease had
ndash no greater risk for adverse fetal outcomes than women with either GDM or periodontal disease alone
Conclusions bull Women in this study with the combination of GDM
plus periodontal disease had
ndash a 23-fold greater risk for developing adverse maternal outcomes than women with either GDM or periodontal disease alone bull Probing pocket depth independent of GDM status was a
significant predictor of adverse pregnancy outcomes (p=001)
bull Bleeding on probing was related to adverse pregnancy outcomes (p=007)
bull GDM status was related to probing pocket depth (p=008)
ndash no greater risk for adverse fetal outcomes than women with either GDM or periodontal disease alone
Exploring the possible biology of an oral-systemic link
ldquoOral health is integral to general healthrdquo
A ldquosilent epidemic of oral diseases is affecting our most vulnerable citizensrdquo
How could periodontal disease contribute to systemic
conditions
Defining periodontal disease
bull An inflammatory disease that is initiated by the
accumulation of Gram-negative bacteria around the
teeth and gums
Potential mechanisms
bull Dissemination of periodontal infection
bull Dissemination of periodontal inflammation
Is there evidence that periodontal bacteria play a major role
bull ldquoGuilt by associationrdquo
ndash Periodontal bacteria rarely found in systemic organs
ndash Case of fetal demise due to oral Fusobacterial infection extremely rare
ndash No cases of stroke or myocardial infarction due to periodontal infection
Letrsquos look at inflammation as a potential culprit
Inflammation
bull Initiates the host response to challenge
bull Brings immune cells and molecules to the site of challenge
bull A tightly regulated mechanism
bull When dysregulated leads to pathology
ndash Genetic (polymorphisms in gene structure)
ndash Environmental (smoking stress diet)
ndash Systemic (obesity type 2 diabetes hormonal)
Including
Periodontal disease
Periodontal disease and systemic disease
bull Risk indicator or risk factor
ndash Risk indicator ndash periodontal disease and the systemic condition share common etiologies
ndash Risk factor ndash oral infectioninflammation contributes to the genesis of the systemic condition Remove periodontal disease and the systemic condition improves
What is the evidence
bull Cross sectional studies
ndash periodontal disease may be a risk indicator for systemic inflammatory conditions in certain populations
ndash failed to show a causal effect suggesting that periodontal disease is not a risk factor for systemic disease
What is the answer
bull Periodontitis and systemic inflammatory conditions have complex etiologies
bull Influenced by
ndash Socio-economic status
ndash Lifestyle choicesbehaviors
bull Diet stress smoking drug abuse
ndash Genetics family history a good predictor
bull Infection
bull Inflammation
The answer may lie in complex interactions between multiple components of susceptibility This may make it very difficult to show a direct causal relationship between periodontal disease and systemic conditions
Thank you
KarenFNovakuthtmcedu
References Dasanayake AP1 Chhun N Tanner AC Craig RG Lee MJ Moore AF Norman RG J Dent Res 2008 Periodontal pathogens and gestational diabetes mellitus 2008 Apr87(4)328-33 Xiong X1 Elkind-Hirsch KE Vastardis S Delarosa RL Pridjian G Buekens P Periodontal disease is associated with gestational diabetes mellitus a case-control study J Periodontol 2009 Nov80(11)1742-9 Ruiz DR1 Romito GA Dib SA Periodontal disease in gestational and type 1 diabetes mellitus pregnant women Oral Dis 2011 Jul17(5)515-21 Xiong X Elkind-Hirsch KE Xie Y Delarosa R Maney P Pridjian G Buekens P Periodontal disease as a potential risk factor for the development of diabetes in women with a prior history of gestational diabetes mellitus J Public Health Dent 2013 Winter73(1)41-9 Michalowicz BS Hodges JS DiANgelis AJ Lupo VR Novak MJ Ferguson JE et al Treatment of periodontal disease and the risk of preterm birth N Engl J Med 2006 3551885-94 Offenbacher S Beck JD Jared HL Maaureilllo SM Mendoza LC Couper DJ et al Effects of periodontal therapy on rate or preterm delivery a randomized controlled trial Maternal Oral Therapy to Reduce Obstetric Risk (MOTOR) Investigators Obstet Gynecol 2009 114551-9 Committee on Health Care for Underserved Women Committee Opinion Oral health care during pregnancy and through the lifespan 2013 122417-422
GDM Risk Factors
bull Obesity
bull Previous history of GDM
bull Family history of diabetes
bull Having given birth previously to a very large infant a still birth or a child with a birth defect
bull Having too much amniotic fluid
bull Being gt25 years of age
bull Being African American HispanicLatina American American Indian
ndash Positive (gt200 mgdL) bull Diagnostic no further test needed
GDM Testing and Diagnosis bull GTT
ndash Overnight fast followed by 100 gm glucose administration
ndash Fasting 1 2 and 3 hour plasma levels obtained
ndash Two values gt normal are diagnostic bull Fasting 105 mgdL
bull 1 hour 190 mgdL
bull 2 hours 165 mgdL
bull 3 hours 145 mgdL
GDM Testing and Diagnosis
bull Average risk women
ndash Tested between 24-28 weeks gestation
bull High risk women
ndash Tested as soon as possible
GDM Potential Negative Outcomes
bull After pregnancy 5-10 of women with GDM develop type 2 diabetes mellitus
bull Women who have had GDM have a 20-50 chance of developing type 2 diabetes in the next 5-10 years
Study 1 NHANES III Analysis
Novak KF Taylor G Ferguson JE and Novak MJ 2006 Periodontitis and Gestational Diabetes Mellitus Exploring the Link in NHANES III J Pub Health Dent 66163-168
Periodontal Disease and GDM bull 4244 women ages 20-59
ndash 113 had a history of GDM during pregnancy
bull Periodontal disease defined as one or more teeth with one or more sites with PDgt4mm LOA gt2mm and bleeding on probing
bull There was a trend for women with a history of GDM to have more periodontal disease than women without a history of GDM
Hypothesis Fig 1
Gestational Diabetes Mellitus Periodontal Disease
Negative Maternal and Fetal Outcomes
Combined Effect
Novak KF Taylor G Ferguson JE and Novak MJ 2006 Periodontitis and Gestational Diabetes Mellitus
Exploring the Link in NHANES III J Pub Health Dent 66163-168
Periodontal Disease and GDM bull Prior GDM higher pre-pregnancy BMI vaginal levels of Tannerella forsythia and C-
reactive protein were risk factors for developing GDM Periodontal disease was not statistically significant Dasanayakeet al 2008
ldquoNew Evidence of Periodontal Disease Leading to Gestational Diabetesrdquo
bull Further support for the hypothesis that there is an association between periodontal disease and GDM Xiong et al 2009
bull The presence of periodontal disease was significantly higher in women with either GDM or Type 2 diabetes during their pregnancy Age pregestational BMI and HbA1c) were related to clinical attachment loss in these two group Ruiz et al 2011
bull Women with both prior GDM and periodontal disease showed greater insulin resistance and altered Beta cell function potentially making them at greater risk for developing Type 2 diabetes Xiong et al 2012
Study 2 NIH Cross-Sectional Analysis
NIHNCRR Center of Biomedical Research Excellence P20 RR020145
University of Kentucky CR-DOC
Study Population
bull 306 matched pairs of pregnant women ndash Ages 16-45
ndash No history of type 1 or type 2 diabetes mellitus
ndash Minimum of 20 teeth
bull 153 with GDM 153 controls without GDM ndash Age raceethnicity and gestational age matched
bull Categorized by presenceabsence of periodontal disease (PD)
Data Collection bull Enrollment
ndash Consent and HIPAA authorization
ndash Medical and dental histories
ndash Comprehensive periodontal examination
bull Plaque index probing pocket depths clinical
attachment levels bleeding index calculus index
ndash Periodontitis (PD)
bull At least 4 teeth with PD gt4mm LOA gt2mm and
BOP
Data Collection
Laboratory samples
bull Serum ndash assessed by ELISA and Luminex
bull Subgingival plaque ndash biofilm microbiota assessed by qPCR
Data collection bull Post-delivery maternal and fetal outcomes
ndash Maternal pre-eclampsia premature labor premature rupture of membranes urinary tract infections chorioamnionitisfunisitis induction of labor operative vaginal deliveries or unplanned cesarean
Multivariable logistic regression GEE adjusted for smoking and calculus Variables used for matching were not used as covariates in the GEE matched analysis regression
modeling These included age raceethnicity and gestational age at enrollment
Conclusion bull Women in this study with the combination of GDM
plus periodontal disease had
ndash a 23-fold greater risk for developing adverse maternal outcomes than women with either GDM or periodontal disease alone
Fig 1
Gestational Diabetes Mellitus Periodontal Disease
Negative Maternal and Fetal Outcomes
Combined Effect
Periodontal Variable
Adverse pregnancy outcomes
n=130
No adverse pregnancy outcomes
n=176
P- value (Wilcoxon test)
Plaque index 056 (019) 053 (017) 008
Probing depth 28 (051) 27 (056) 001
Clinical attachment loss
063 (055) 062 (055) 084
Calculus (0-3) 044 (037) 039 (037) 017
Bleeding (0-3) 036 (030) 033 (031) 007
Case Control Comparison
Periodontal Variable
GDM + n=153
GDM ndash n=153
(P- value) (Wilcoxon
test)
Plaque index 055 (017) 053 (019) 026
Probing depth 28 (057) 27 (049) 008
Clinical attachment loss
066 (056) 058 (054) 021
Calculus (0-3) 044 (037) 039 (037) 020
Bleeding (0-3) 037 (031) 032 (030) 021
Case Control Comparison
Conclusions bull Probing pocket depth independent of GDM
status was a significant predictor of adverse pregnancy outcomes (p=001)
bull Bleeding on probing was related to adverse pregnancy outcomes (p=007)
bull GDM status was related to probing pocket depth (p=008)
Odds Ratios for Adverse Fetal Outcomes
Contrasts for PD and GDM status Odds Ratio 95 CI
PD+ GDM+ vs PD- GDM- 142 064 314
PD+ GDM+ vs PD- GDM+ 147 066 327
PD+ GDM+ vs PD+ GDM- 119 058 242
Multivariable logistic regression GEE adjusted for smoking and calculus Variables used for matching were not used as covariates in the GEE matched analysis regression
modeling These included age raceethnicity and gestational age at enrollment
Conclusion bull Women in this study with the combination of GDM
plus periodontal disease had
ndash no greater risk for adverse fetal outcomes than women with either GDM or periodontal disease alone
Conclusions bull Women in this study with the combination of GDM
plus periodontal disease had
ndash a 23-fold greater risk for developing adverse maternal outcomes than women with either GDM or periodontal disease alone bull Probing pocket depth independent of GDM status was a
significant predictor of adverse pregnancy outcomes (p=001)
bull Bleeding on probing was related to adverse pregnancy outcomes (p=007)
bull GDM status was related to probing pocket depth (p=008)
ndash no greater risk for adverse fetal outcomes than women with either GDM or periodontal disease alone
Exploring the possible biology of an oral-systemic link
ldquoOral health is integral to general healthrdquo
A ldquosilent epidemic of oral diseases is affecting our most vulnerable citizensrdquo
How could periodontal disease contribute to systemic
conditions
Defining periodontal disease
bull An inflammatory disease that is initiated by the
accumulation of Gram-negative bacteria around the
teeth and gums
Potential mechanisms
bull Dissemination of periodontal infection
bull Dissemination of periodontal inflammation
Is there evidence that periodontal bacteria play a major role
bull ldquoGuilt by associationrdquo
ndash Periodontal bacteria rarely found in systemic organs
ndash Case of fetal demise due to oral Fusobacterial infection extremely rare
ndash No cases of stroke or myocardial infarction due to periodontal infection
Letrsquos look at inflammation as a potential culprit
Inflammation
bull Initiates the host response to challenge
bull Brings immune cells and molecules to the site of challenge
bull A tightly regulated mechanism
bull When dysregulated leads to pathology
ndash Genetic (polymorphisms in gene structure)
ndash Environmental (smoking stress diet)
ndash Systemic (obesity type 2 diabetes hormonal)
Including
Periodontal disease
Periodontal disease and systemic disease
bull Risk indicator or risk factor
ndash Risk indicator ndash periodontal disease and the systemic condition share common etiologies
ndash Risk factor ndash oral infectioninflammation contributes to the genesis of the systemic condition Remove periodontal disease and the systemic condition improves
What is the evidence
bull Cross sectional studies
ndash periodontal disease may be a risk indicator for systemic inflammatory conditions in certain populations
ndash failed to show a causal effect suggesting that periodontal disease is not a risk factor for systemic disease
What is the answer
bull Periodontitis and systemic inflammatory conditions have complex etiologies
bull Influenced by
ndash Socio-economic status
ndash Lifestyle choicesbehaviors
bull Diet stress smoking drug abuse
ndash Genetics family history a good predictor
bull Infection
bull Inflammation
The answer may lie in complex interactions between multiple components of susceptibility This may make it very difficult to show a direct causal relationship between periodontal disease and systemic conditions
Thank you
KarenFNovakuthtmcedu
References Dasanayake AP1 Chhun N Tanner AC Craig RG Lee MJ Moore AF Norman RG J Dent Res 2008 Periodontal pathogens and gestational diabetes mellitus 2008 Apr87(4)328-33 Xiong X1 Elkind-Hirsch KE Vastardis S Delarosa RL Pridjian G Buekens P Periodontal disease is associated with gestational diabetes mellitus a case-control study J Periodontol 2009 Nov80(11)1742-9 Ruiz DR1 Romito GA Dib SA Periodontal disease in gestational and type 1 diabetes mellitus pregnant women Oral Dis 2011 Jul17(5)515-21 Xiong X Elkind-Hirsch KE Xie Y Delarosa R Maney P Pridjian G Buekens P Periodontal disease as a potential risk factor for the development of diabetes in women with a prior history of gestational diabetes mellitus J Public Health Dent 2013 Winter73(1)41-9 Michalowicz BS Hodges JS DiANgelis AJ Lupo VR Novak MJ Ferguson JE et al Treatment of periodontal disease and the risk of preterm birth N Engl J Med 2006 3551885-94 Offenbacher S Beck JD Jared HL Maaureilllo SM Mendoza LC Couper DJ et al Effects of periodontal therapy on rate or preterm delivery a randomized controlled trial Maternal Oral Therapy to Reduce Obstetric Risk (MOTOR) Investigators Obstet Gynecol 2009 114551-9 Committee on Health Care for Underserved Women Committee Opinion Oral health care during pregnancy and through the lifespan 2013 122417-422
ndash Positive (gt200 mgdL) bull Diagnostic no further test needed
GDM Testing and Diagnosis bull GTT
ndash Overnight fast followed by 100 gm glucose administration
ndash Fasting 1 2 and 3 hour plasma levels obtained
ndash Two values gt normal are diagnostic bull Fasting 105 mgdL
bull 1 hour 190 mgdL
bull 2 hours 165 mgdL
bull 3 hours 145 mgdL
GDM Testing and Diagnosis
bull Average risk women
ndash Tested between 24-28 weeks gestation
bull High risk women
ndash Tested as soon as possible
GDM Potential Negative Outcomes
bull After pregnancy 5-10 of women with GDM develop type 2 diabetes mellitus
bull Women who have had GDM have a 20-50 chance of developing type 2 diabetes in the next 5-10 years
Study 1 NHANES III Analysis
Novak KF Taylor G Ferguson JE and Novak MJ 2006 Periodontitis and Gestational Diabetes Mellitus Exploring the Link in NHANES III J Pub Health Dent 66163-168
Periodontal Disease and GDM bull 4244 women ages 20-59
ndash 113 had a history of GDM during pregnancy
bull Periodontal disease defined as one or more teeth with one or more sites with PDgt4mm LOA gt2mm and bleeding on probing
bull There was a trend for women with a history of GDM to have more periodontal disease than women without a history of GDM
Hypothesis Fig 1
Gestational Diabetes Mellitus Periodontal Disease
Negative Maternal and Fetal Outcomes
Combined Effect
Novak KF Taylor G Ferguson JE and Novak MJ 2006 Periodontitis and Gestational Diabetes Mellitus
Exploring the Link in NHANES III J Pub Health Dent 66163-168
Periodontal Disease and GDM bull Prior GDM higher pre-pregnancy BMI vaginal levels of Tannerella forsythia and C-
reactive protein were risk factors for developing GDM Periodontal disease was not statistically significant Dasanayakeet al 2008
ldquoNew Evidence of Periodontal Disease Leading to Gestational Diabetesrdquo
bull Further support for the hypothesis that there is an association between periodontal disease and GDM Xiong et al 2009
bull The presence of periodontal disease was significantly higher in women with either GDM or Type 2 diabetes during their pregnancy Age pregestational BMI and HbA1c) were related to clinical attachment loss in these two group Ruiz et al 2011
bull Women with both prior GDM and periodontal disease showed greater insulin resistance and altered Beta cell function potentially making them at greater risk for developing Type 2 diabetes Xiong et al 2012
Study 2 NIH Cross-Sectional Analysis
NIHNCRR Center of Biomedical Research Excellence P20 RR020145
University of Kentucky CR-DOC
Study Population
bull 306 matched pairs of pregnant women ndash Ages 16-45
ndash No history of type 1 or type 2 diabetes mellitus
ndash Minimum of 20 teeth
bull 153 with GDM 153 controls without GDM ndash Age raceethnicity and gestational age matched
bull Categorized by presenceabsence of periodontal disease (PD)
Data Collection bull Enrollment
ndash Consent and HIPAA authorization
ndash Medical and dental histories
ndash Comprehensive periodontal examination
bull Plaque index probing pocket depths clinical
attachment levels bleeding index calculus index
ndash Periodontitis (PD)
bull At least 4 teeth with PD gt4mm LOA gt2mm and
BOP
Data Collection
Laboratory samples
bull Serum ndash assessed by ELISA and Luminex
bull Subgingival plaque ndash biofilm microbiota assessed by qPCR
Data collection bull Post-delivery maternal and fetal outcomes
ndash Maternal pre-eclampsia premature labor premature rupture of membranes urinary tract infections chorioamnionitisfunisitis induction of labor operative vaginal deliveries or unplanned cesarean
Multivariable logistic regression GEE adjusted for smoking and calculus Variables used for matching were not used as covariates in the GEE matched analysis regression
modeling These included age raceethnicity and gestational age at enrollment
Conclusion bull Women in this study with the combination of GDM
plus periodontal disease had
ndash a 23-fold greater risk for developing adverse maternal outcomes than women with either GDM or periodontal disease alone
Fig 1
Gestational Diabetes Mellitus Periodontal Disease
Negative Maternal and Fetal Outcomes
Combined Effect
Periodontal Variable
Adverse pregnancy outcomes
n=130
No adverse pregnancy outcomes
n=176
P- value (Wilcoxon test)
Plaque index 056 (019) 053 (017) 008
Probing depth 28 (051) 27 (056) 001
Clinical attachment loss
063 (055) 062 (055) 084
Calculus (0-3) 044 (037) 039 (037) 017
Bleeding (0-3) 036 (030) 033 (031) 007
Case Control Comparison
Periodontal Variable
GDM + n=153
GDM ndash n=153
(P- value) (Wilcoxon
test)
Plaque index 055 (017) 053 (019) 026
Probing depth 28 (057) 27 (049) 008
Clinical attachment loss
066 (056) 058 (054) 021
Calculus (0-3) 044 (037) 039 (037) 020
Bleeding (0-3) 037 (031) 032 (030) 021
Case Control Comparison
Conclusions bull Probing pocket depth independent of GDM
status was a significant predictor of adverse pregnancy outcomes (p=001)
bull Bleeding on probing was related to adverse pregnancy outcomes (p=007)
bull GDM status was related to probing pocket depth (p=008)
Odds Ratios for Adverse Fetal Outcomes
Contrasts for PD and GDM status Odds Ratio 95 CI
PD+ GDM+ vs PD- GDM- 142 064 314
PD+ GDM+ vs PD- GDM+ 147 066 327
PD+ GDM+ vs PD+ GDM- 119 058 242
Multivariable logistic regression GEE adjusted for smoking and calculus Variables used for matching were not used as covariates in the GEE matched analysis regression
modeling These included age raceethnicity and gestational age at enrollment
Conclusion bull Women in this study with the combination of GDM
plus periodontal disease had
ndash no greater risk for adverse fetal outcomes than women with either GDM or periodontal disease alone
Conclusions bull Women in this study with the combination of GDM
plus periodontal disease had
ndash a 23-fold greater risk for developing adverse maternal outcomes than women with either GDM or periodontal disease alone bull Probing pocket depth independent of GDM status was a
significant predictor of adverse pregnancy outcomes (p=001)
bull Bleeding on probing was related to adverse pregnancy outcomes (p=007)
bull GDM status was related to probing pocket depth (p=008)
ndash no greater risk for adverse fetal outcomes than women with either GDM or periodontal disease alone
Exploring the possible biology of an oral-systemic link
ldquoOral health is integral to general healthrdquo
A ldquosilent epidemic of oral diseases is affecting our most vulnerable citizensrdquo
How could periodontal disease contribute to systemic
conditions
Defining periodontal disease
bull An inflammatory disease that is initiated by the
accumulation of Gram-negative bacteria around the
teeth and gums
Potential mechanisms
bull Dissemination of periodontal infection
bull Dissemination of periodontal inflammation
Is there evidence that periodontal bacteria play a major role
bull ldquoGuilt by associationrdquo
ndash Periodontal bacteria rarely found in systemic organs
ndash Case of fetal demise due to oral Fusobacterial infection extremely rare
ndash No cases of stroke or myocardial infarction due to periodontal infection
Letrsquos look at inflammation as a potential culprit
Inflammation
bull Initiates the host response to challenge
bull Brings immune cells and molecules to the site of challenge
bull A tightly regulated mechanism
bull When dysregulated leads to pathology
ndash Genetic (polymorphisms in gene structure)
ndash Environmental (smoking stress diet)
ndash Systemic (obesity type 2 diabetes hormonal)
Including
Periodontal disease
Periodontal disease and systemic disease
bull Risk indicator or risk factor
ndash Risk indicator ndash periodontal disease and the systemic condition share common etiologies
ndash Risk factor ndash oral infectioninflammation contributes to the genesis of the systemic condition Remove periodontal disease and the systemic condition improves
What is the evidence
bull Cross sectional studies
ndash periodontal disease may be a risk indicator for systemic inflammatory conditions in certain populations
ndash failed to show a causal effect suggesting that periodontal disease is not a risk factor for systemic disease
What is the answer
bull Periodontitis and systemic inflammatory conditions have complex etiologies
bull Influenced by
ndash Socio-economic status
ndash Lifestyle choicesbehaviors
bull Diet stress smoking drug abuse
ndash Genetics family history a good predictor
bull Infection
bull Inflammation
The answer may lie in complex interactions between multiple components of susceptibility This may make it very difficult to show a direct causal relationship between periodontal disease and systemic conditions
Thank you
KarenFNovakuthtmcedu
References Dasanayake AP1 Chhun N Tanner AC Craig RG Lee MJ Moore AF Norman RG J Dent Res 2008 Periodontal pathogens and gestational diabetes mellitus 2008 Apr87(4)328-33 Xiong X1 Elkind-Hirsch KE Vastardis S Delarosa RL Pridjian G Buekens P Periodontal disease is associated with gestational diabetes mellitus a case-control study J Periodontol 2009 Nov80(11)1742-9 Ruiz DR1 Romito GA Dib SA Periodontal disease in gestational and type 1 diabetes mellitus pregnant women Oral Dis 2011 Jul17(5)515-21 Xiong X Elkind-Hirsch KE Xie Y Delarosa R Maney P Pridjian G Buekens P Periodontal disease as a potential risk factor for the development of diabetes in women with a prior history of gestational diabetes mellitus J Public Health Dent 2013 Winter73(1)41-9 Michalowicz BS Hodges JS DiANgelis AJ Lupo VR Novak MJ Ferguson JE et al Treatment of periodontal disease and the risk of preterm birth N Engl J Med 2006 3551885-94 Offenbacher S Beck JD Jared HL Maaureilllo SM Mendoza LC Couper DJ et al Effects of periodontal therapy on rate or preterm delivery a randomized controlled trial Maternal Oral Therapy to Reduce Obstetric Risk (MOTOR) Investigators Obstet Gynecol 2009 114551-9 Committee on Health Care for Underserved Women Committee Opinion Oral health care during pregnancy and through the lifespan 2013 122417-422
GDM Testing and Diagnosis bull GTT
ndash Overnight fast followed by 100 gm glucose administration
ndash Fasting 1 2 and 3 hour plasma levels obtained
ndash Two values gt normal are diagnostic bull Fasting 105 mgdL
bull 1 hour 190 mgdL
bull 2 hours 165 mgdL
bull 3 hours 145 mgdL
GDM Testing and Diagnosis
bull Average risk women
ndash Tested between 24-28 weeks gestation
bull High risk women
ndash Tested as soon as possible
GDM Potential Negative Outcomes
bull After pregnancy 5-10 of women with GDM develop type 2 diabetes mellitus
bull Women who have had GDM have a 20-50 chance of developing type 2 diabetes in the next 5-10 years
Study 1 NHANES III Analysis
Novak KF Taylor G Ferguson JE and Novak MJ 2006 Periodontitis and Gestational Diabetes Mellitus Exploring the Link in NHANES III J Pub Health Dent 66163-168
Periodontal Disease and GDM bull 4244 women ages 20-59
ndash 113 had a history of GDM during pregnancy
bull Periodontal disease defined as one or more teeth with one or more sites with PDgt4mm LOA gt2mm and bleeding on probing
bull There was a trend for women with a history of GDM to have more periodontal disease than women without a history of GDM
Hypothesis Fig 1
Gestational Diabetes Mellitus Periodontal Disease
Negative Maternal and Fetal Outcomes
Combined Effect
Novak KF Taylor G Ferguson JE and Novak MJ 2006 Periodontitis and Gestational Diabetes Mellitus
Exploring the Link in NHANES III J Pub Health Dent 66163-168
Periodontal Disease and GDM bull Prior GDM higher pre-pregnancy BMI vaginal levels of Tannerella forsythia and C-
reactive protein were risk factors for developing GDM Periodontal disease was not statistically significant Dasanayakeet al 2008
ldquoNew Evidence of Periodontal Disease Leading to Gestational Diabetesrdquo
bull Further support for the hypothesis that there is an association between periodontal disease and GDM Xiong et al 2009
bull The presence of periodontal disease was significantly higher in women with either GDM or Type 2 diabetes during their pregnancy Age pregestational BMI and HbA1c) were related to clinical attachment loss in these two group Ruiz et al 2011
bull Women with both prior GDM and periodontal disease showed greater insulin resistance and altered Beta cell function potentially making them at greater risk for developing Type 2 diabetes Xiong et al 2012
Study 2 NIH Cross-Sectional Analysis
NIHNCRR Center of Biomedical Research Excellence P20 RR020145
University of Kentucky CR-DOC
Study Population
bull 306 matched pairs of pregnant women ndash Ages 16-45
ndash No history of type 1 or type 2 diabetes mellitus
ndash Minimum of 20 teeth
bull 153 with GDM 153 controls without GDM ndash Age raceethnicity and gestational age matched
bull Categorized by presenceabsence of periodontal disease (PD)
Data Collection bull Enrollment
ndash Consent and HIPAA authorization
ndash Medical and dental histories
ndash Comprehensive periodontal examination
bull Plaque index probing pocket depths clinical
attachment levels bleeding index calculus index
ndash Periodontitis (PD)
bull At least 4 teeth with PD gt4mm LOA gt2mm and
BOP
Data Collection
Laboratory samples
bull Serum ndash assessed by ELISA and Luminex
bull Subgingival plaque ndash biofilm microbiota assessed by qPCR
Data collection bull Post-delivery maternal and fetal outcomes
ndash Maternal pre-eclampsia premature labor premature rupture of membranes urinary tract infections chorioamnionitisfunisitis induction of labor operative vaginal deliveries or unplanned cesarean
Multivariable logistic regression GEE adjusted for smoking and calculus Variables used for matching were not used as covariates in the GEE matched analysis regression
modeling These included age raceethnicity and gestational age at enrollment
Conclusion bull Women in this study with the combination of GDM
plus periodontal disease had
ndash a 23-fold greater risk for developing adverse maternal outcomes than women with either GDM or periodontal disease alone
Fig 1
Gestational Diabetes Mellitus Periodontal Disease
Negative Maternal and Fetal Outcomes
Combined Effect
Periodontal Variable
Adverse pregnancy outcomes
n=130
No adverse pregnancy outcomes
n=176
P- value (Wilcoxon test)
Plaque index 056 (019) 053 (017) 008
Probing depth 28 (051) 27 (056) 001
Clinical attachment loss
063 (055) 062 (055) 084
Calculus (0-3) 044 (037) 039 (037) 017
Bleeding (0-3) 036 (030) 033 (031) 007
Case Control Comparison
Periodontal Variable
GDM + n=153
GDM ndash n=153
(P- value) (Wilcoxon
test)
Plaque index 055 (017) 053 (019) 026
Probing depth 28 (057) 27 (049) 008
Clinical attachment loss
066 (056) 058 (054) 021
Calculus (0-3) 044 (037) 039 (037) 020
Bleeding (0-3) 037 (031) 032 (030) 021
Case Control Comparison
Conclusions bull Probing pocket depth independent of GDM
status was a significant predictor of adverse pregnancy outcomes (p=001)
bull Bleeding on probing was related to adverse pregnancy outcomes (p=007)
bull GDM status was related to probing pocket depth (p=008)
Odds Ratios for Adverse Fetal Outcomes
Contrasts for PD and GDM status Odds Ratio 95 CI
PD+ GDM+ vs PD- GDM- 142 064 314
PD+ GDM+ vs PD- GDM+ 147 066 327
PD+ GDM+ vs PD+ GDM- 119 058 242
Multivariable logistic regression GEE adjusted for smoking and calculus Variables used for matching were not used as covariates in the GEE matched analysis regression
modeling These included age raceethnicity and gestational age at enrollment
Conclusion bull Women in this study with the combination of GDM
plus periodontal disease had
ndash no greater risk for adverse fetal outcomes than women with either GDM or periodontal disease alone
Conclusions bull Women in this study with the combination of GDM
plus periodontal disease had
ndash a 23-fold greater risk for developing adverse maternal outcomes than women with either GDM or periodontal disease alone bull Probing pocket depth independent of GDM status was a
significant predictor of adverse pregnancy outcomes (p=001)
bull Bleeding on probing was related to adverse pregnancy outcomes (p=007)
bull GDM status was related to probing pocket depth (p=008)
ndash no greater risk for adverse fetal outcomes than women with either GDM or periodontal disease alone
Exploring the possible biology of an oral-systemic link
ldquoOral health is integral to general healthrdquo
A ldquosilent epidemic of oral diseases is affecting our most vulnerable citizensrdquo
How could periodontal disease contribute to systemic
conditions
Defining periodontal disease
bull An inflammatory disease that is initiated by the
accumulation of Gram-negative bacteria around the
teeth and gums
Potential mechanisms
bull Dissemination of periodontal infection
bull Dissemination of periodontal inflammation
Is there evidence that periodontal bacteria play a major role
bull ldquoGuilt by associationrdquo
ndash Periodontal bacteria rarely found in systemic organs
ndash Case of fetal demise due to oral Fusobacterial infection extremely rare
ndash No cases of stroke or myocardial infarction due to periodontal infection
Letrsquos look at inflammation as a potential culprit
Inflammation
bull Initiates the host response to challenge
bull Brings immune cells and molecules to the site of challenge
bull A tightly regulated mechanism
bull When dysregulated leads to pathology
ndash Genetic (polymorphisms in gene structure)
ndash Environmental (smoking stress diet)
ndash Systemic (obesity type 2 diabetes hormonal)
Including
Periodontal disease
Periodontal disease and systemic disease
bull Risk indicator or risk factor
ndash Risk indicator ndash periodontal disease and the systemic condition share common etiologies
ndash Risk factor ndash oral infectioninflammation contributes to the genesis of the systemic condition Remove periodontal disease and the systemic condition improves
What is the evidence
bull Cross sectional studies
ndash periodontal disease may be a risk indicator for systemic inflammatory conditions in certain populations
ndash failed to show a causal effect suggesting that periodontal disease is not a risk factor for systemic disease
What is the answer
bull Periodontitis and systemic inflammatory conditions have complex etiologies
bull Influenced by
ndash Socio-economic status
ndash Lifestyle choicesbehaviors
bull Diet stress smoking drug abuse
ndash Genetics family history a good predictor
bull Infection
bull Inflammation
The answer may lie in complex interactions between multiple components of susceptibility This may make it very difficult to show a direct causal relationship between periodontal disease and systemic conditions
Thank you
KarenFNovakuthtmcedu
References Dasanayake AP1 Chhun N Tanner AC Craig RG Lee MJ Moore AF Norman RG J Dent Res 2008 Periodontal pathogens and gestational diabetes mellitus 2008 Apr87(4)328-33 Xiong X1 Elkind-Hirsch KE Vastardis S Delarosa RL Pridjian G Buekens P Periodontal disease is associated with gestational diabetes mellitus a case-control study J Periodontol 2009 Nov80(11)1742-9 Ruiz DR1 Romito GA Dib SA Periodontal disease in gestational and type 1 diabetes mellitus pregnant women Oral Dis 2011 Jul17(5)515-21 Xiong X Elkind-Hirsch KE Xie Y Delarosa R Maney P Pridjian G Buekens P Periodontal disease as a potential risk factor for the development of diabetes in women with a prior history of gestational diabetes mellitus J Public Health Dent 2013 Winter73(1)41-9 Michalowicz BS Hodges JS DiANgelis AJ Lupo VR Novak MJ Ferguson JE et al Treatment of periodontal disease and the risk of preterm birth N Engl J Med 2006 3551885-94 Offenbacher S Beck JD Jared HL Maaureilllo SM Mendoza LC Couper DJ et al Effects of periodontal therapy on rate or preterm delivery a randomized controlled trial Maternal Oral Therapy to Reduce Obstetric Risk (MOTOR) Investigators Obstet Gynecol 2009 114551-9 Committee on Health Care for Underserved Women Committee Opinion Oral health care during pregnancy and through the lifespan 2013 122417-422
GDM Testing and Diagnosis
bull Average risk women
ndash Tested between 24-28 weeks gestation
bull High risk women
ndash Tested as soon as possible
GDM Potential Negative Outcomes
bull After pregnancy 5-10 of women with GDM develop type 2 diabetes mellitus
bull Women who have had GDM have a 20-50 chance of developing type 2 diabetes in the next 5-10 years
Study 1 NHANES III Analysis
Novak KF Taylor G Ferguson JE and Novak MJ 2006 Periodontitis and Gestational Diabetes Mellitus Exploring the Link in NHANES III J Pub Health Dent 66163-168
Periodontal Disease and GDM bull 4244 women ages 20-59
ndash 113 had a history of GDM during pregnancy
bull Periodontal disease defined as one or more teeth with one or more sites with PDgt4mm LOA gt2mm and bleeding on probing
bull There was a trend for women with a history of GDM to have more periodontal disease than women without a history of GDM
Hypothesis Fig 1
Gestational Diabetes Mellitus Periodontal Disease
Negative Maternal and Fetal Outcomes
Combined Effect
Novak KF Taylor G Ferguson JE and Novak MJ 2006 Periodontitis and Gestational Diabetes Mellitus
Exploring the Link in NHANES III J Pub Health Dent 66163-168
Periodontal Disease and GDM bull Prior GDM higher pre-pregnancy BMI vaginal levels of Tannerella forsythia and C-
reactive protein were risk factors for developing GDM Periodontal disease was not statistically significant Dasanayakeet al 2008
ldquoNew Evidence of Periodontal Disease Leading to Gestational Diabetesrdquo
bull Further support for the hypothesis that there is an association between periodontal disease and GDM Xiong et al 2009
bull The presence of periodontal disease was significantly higher in women with either GDM or Type 2 diabetes during their pregnancy Age pregestational BMI and HbA1c) were related to clinical attachment loss in these two group Ruiz et al 2011
bull Women with both prior GDM and periodontal disease showed greater insulin resistance and altered Beta cell function potentially making them at greater risk for developing Type 2 diabetes Xiong et al 2012
Study 2 NIH Cross-Sectional Analysis
NIHNCRR Center of Biomedical Research Excellence P20 RR020145
University of Kentucky CR-DOC
Study Population
bull 306 matched pairs of pregnant women ndash Ages 16-45
ndash No history of type 1 or type 2 diabetes mellitus
ndash Minimum of 20 teeth
bull 153 with GDM 153 controls without GDM ndash Age raceethnicity and gestational age matched
bull Categorized by presenceabsence of periodontal disease (PD)
Data Collection bull Enrollment
ndash Consent and HIPAA authorization
ndash Medical and dental histories
ndash Comprehensive periodontal examination
bull Plaque index probing pocket depths clinical
attachment levels bleeding index calculus index
ndash Periodontitis (PD)
bull At least 4 teeth with PD gt4mm LOA gt2mm and
BOP
Data Collection
Laboratory samples
bull Serum ndash assessed by ELISA and Luminex
bull Subgingival plaque ndash biofilm microbiota assessed by qPCR
Data collection bull Post-delivery maternal and fetal outcomes
ndash Maternal pre-eclampsia premature labor premature rupture of membranes urinary tract infections chorioamnionitisfunisitis induction of labor operative vaginal deliveries or unplanned cesarean
Multivariable logistic regression GEE adjusted for smoking and calculus Variables used for matching were not used as covariates in the GEE matched analysis regression
modeling These included age raceethnicity and gestational age at enrollment
Conclusion bull Women in this study with the combination of GDM
plus periodontal disease had
ndash a 23-fold greater risk for developing adverse maternal outcomes than women with either GDM or periodontal disease alone
Fig 1
Gestational Diabetes Mellitus Periodontal Disease
Negative Maternal and Fetal Outcomes
Combined Effect
Periodontal Variable
Adverse pregnancy outcomes
n=130
No adverse pregnancy outcomes
n=176
P- value (Wilcoxon test)
Plaque index 056 (019) 053 (017) 008
Probing depth 28 (051) 27 (056) 001
Clinical attachment loss
063 (055) 062 (055) 084
Calculus (0-3) 044 (037) 039 (037) 017
Bleeding (0-3) 036 (030) 033 (031) 007
Case Control Comparison
Periodontal Variable
GDM + n=153
GDM ndash n=153
(P- value) (Wilcoxon
test)
Plaque index 055 (017) 053 (019) 026
Probing depth 28 (057) 27 (049) 008
Clinical attachment loss
066 (056) 058 (054) 021
Calculus (0-3) 044 (037) 039 (037) 020
Bleeding (0-3) 037 (031) 032 (030) 021
Case Control Comparison
Conclusions bull Probing pocket depth independent of GDM
status was a significant predictor of adverse pregnancy outcomes (p=001)
bull Bleeding on probing was related to adverse pregnancy outcomes (p=007)
bull GDM status was related to probing pocket depth (p=008)
Odds Ratios for Adverse Fetal Outcomes
Contrasts for PD and GDM status Odds Ratio 95 CI
PD+ GDM+ vs PD- GDM- 142 064 314
PD+ GDM+ vs PD- GDM+ 147 066 327
PD+ GDM+ vs PD+ GDM- 119 058 242
Multivariable logistic regression GEE adjusted for smoking and calculus Variables used for matching were not used as covariates in the GEE matched analysis regression
modeling These included age raceethnicity and gestational age at enrollment
Conclusion bull Women in this study with the combination of GDM
plus periodontal disease had
ndash no greater risk for adverse fetal outcomes than women with either GDM or periodontal disease alone
Conclusions bull Women in this study with the combination of GDM
plus periodontal disease had
ndash a 23-fold greater risk for developing adverse maternal outcomes than women with either GDM or periodontal disease alone bull Probing pocket depth independent of GDM status was a
significant predictor of adverse pregnancy outcomes (p=001)
bull Bleeding on probing was related to adverse pregnancy outcomes (p=007)
bull GDM status was related to probing pocket depth (p=008)
ndash no greater risk for adverse fetal outcomes than women with either GDM or periodontal disease alone
Exploring the possible biology of an oral-systemic link
ldquoOral health is integral to general healthrdquo
A ldquosilent epidemic of oral diseases is affecting our most vulnerable citizensrdquo
How could periodontal disease contribute to systemic
conditions
Defining periodontal disease
bull An inflammatory disease that is initiated by the
accumulation of Gram-negative bacteria around the
teeth and gums
Potential mechanisms
bull Dissemination of periodontal infection
bull Dissemination of periodontal inflammation
Is there evidence that periodontal bacteria play a major role
bull ldquoGuilt by associationrdquo
ndash Periodontal bacteria rarely found in systemic organs
ndash Case of fetal demise due to oral Fusobacterial infection extremely rare
ndash No cases of stroke or myocardial infarction due to periodontal infection
Letrsquos look at inflammation as a potential culprit
Inflammation
bull Initiates the host response to challenge
bull Brings immune cells and molecules to the site of challenge
bull A tightly regulated mechanism
bull When dysregulated leads to pathology
ndash Genetic (polymorphisms in gene structure)
ndash Environmental (smoking stress diet)
ndash Systemic (obesity type 2 diabetes hormonal)
Including
Periodontal disease
Periodontal disease and systemic disease
bull Risk indicator or risk factor
ndash Risk indicator ndash periodontal disease and the systemic condition share common etiologies
ndash Risk factor ndash oral infectioninflammation contributes to the genesis of the systemic condition Remove periodontal disease and the systemic condition improves
What is the evidence
bull Cross sectional studies
ndash periodontal disease may be a risk indicator for systemic inflammatory conditions in certain populations
ndash failed to show a causal effect suggesting that periodontal disease is not a risk factor for systemic disease
What is the answer
bull Periodontitis and systemic inflammatory conditions have complex etiologies
bull Influenced by
ndash Socio-economic status
ndash Lifestyle choicesbehaviors
bull Diet stress smoking drug abuse
ndash Genetics family history a good predictor
bull Infection
bull Inflammation
The answer may lie in complex interactions between multiple components of susceptibility This may make it very difficult to show a direct causal relationship between periodontal disease and systemic conditions
Thank you
KarenFNovakuthtmcedu
References Dasanayake AP1 Chhun N Tanner AC Craig RG Lee MJ Moore AF Norman RG J Dent Res 2008 Periodontal pathogens and gestational diabetes mellitus 2008 Apr87(4)328-33 Xiong X1 Elkind-Hirsch KE Vastardis S Delarosa RL Pridjian G Buekens P Periodontal disease is associated with gestational diabetes mellitus a case-control study J Periodontol 2009 Nov80(11)1742-9 Ruiz DR1 Romito GA Dib SA Periodontal disease in gestational and type 1 diabetes mellitus pregnant women Oral Dis 2011 Jul17(5)515-21 Xiong X Elkind-Hirsch KE Xie Y Delarosa R Maney P Pridjian G Buekens P Periodontal disease as a potential risk factor for the development of diabetes in women with a prior history of gestational diabetes mellitus J Public Health Dent 2013 Winter73(1)41-9 Michalowicz BS Hodges JS DiANgelis AJ Lupo VR Novak MJ Ferguson JE et al Treatment of periodontal disease and the risk of preterm birth N Engl J Med 2006 3551885-94 Offenbacher S Beck JD Jared HL Maaureilllo SM Mendoza LC Couper DJ et al Effects of periodontal therapy on rate or preterm delivery a randomized controlled trial Maternal Oral Therapy to Reduce Obstetric Risk (MOTOR) Investigators Obstet Gynecol 2009 114551-9 Committee on Health Care for Underserved Women Committee Opinion Oral health care during pregnancy and through the lifespan 2013 122417-422
GDM Potential Negative Outcomes
bull After pregnancy 5-10 of women with GDM develop type 2 diabetes mellitus
bull Women who have had GDM have a 20-50 chance of developing type 2 diabetes in the next 5-10 years
Study 1 NHANES III Analysis
Novak KF Taylor G Ferguson JE and Novak MJ 2006 Periodontitis and Gestational Diabetes Mellitus Exploring the Link in NHANES III J Pub Health Dent 66163-168
Periodontal Disease and GDM bull 4244 women ages 20-59
ndash 113 had a history of GDM during pregnancy
bull Periodontal disease defined as one or more teeth with one or more sites with PDgt4mm LOA gt2mm and bleeding on probing
bull There was a trend for women with a history of GDM to have more periodontal disease than women without a history of GDM
Hypothesis Fig 1
Gestational Diabetes Mellitus Periodontal Disease
Negative Maternal and Fetal Outcomes
Combined Effect
Novak KF Taylor G Ferguson JE and Novak MJ 2006 Periodontitis and Gestational Diabetes Mellitus
Exploring the Link in NHANES III J Pub Health Dent 66163-168
Periodontal Disease and GDM bull Prior GDM higher pre-pregnancy BMI vaginal levels of Tannerella forsythia and C-
reactive protein were risk factors for developing GDM Periodontal disease was not statistically significant Dasanayakeet al 2008
ldquoNew Evidence of Periodontal Disease Leading to Gestational Diabetesrdquo
bull Further support for the hypothesis that there is an association between periodontal disease and GDM Xiong et al 2009
bull The presence of periodontal disease was significantly higher in women with either GDM or Type 2 diabetes during their pregnancy Age pregestational BMI and HbA1c) were related to clinical attachment loss in these two group Ruiz et al 2011
bull Women with both prior GDM and periodontal disease showed greater insulin resistance and altered Beta cell function potentially making them at greater risk for developing Type 2 diabetes Xiong et al 2012
Study 2 NIH Cross-Sectional Analysis
NIHNCRR Center of Biomedical Research Excellence P20 RR020145
University of Kentucky CR-DOC
Study Population
bull 306 matched pairs of pregnant women ndash Ages 16-45
ndash No history of type 1 or type 2 diabetes mellitus
ndash Minimum of 20 teeth
bull 153 with GDM 153 controls without GDM ndash Age raceethnicity and gestational age matched
bull Categorized by presenceabsence of periodontal disease (PD)
Data Collection bull Enrollment
ndash Consent and HIPAA authorization
ndash Medical and dental histories
ndash Comprehensive periodontal examination
bull Plaque index probing pocket depths clinical
attachment levels bleeding index calculus index
ndash Periodontitis (PD)
bull At least 4 teeth with PD gt4mm LOA gt2mm and
BOP
Data Collection
Laboratory samples
bull Serum ndash assessed by ELISA and Luminex
bull Subgingival plaque ndash biofilm microbiota assessed by qPCR
Data collection bull Post-delivery maternal and fetal outcomes
ndash Maternal pre-eclampsia premature labor premature rupture of membranes urinary tract infections chorioamnionitisfunisitis induction of labor operative vaginal deliveries or unplanned cesarean
Multivariable logistic regression GEE adjusted for smoking and calculus Variables used for matching were not used as covariates in the GEE matched analysis regression
modeling These included age raceethnicity and gestational age at enrollment
Conclusion bull Women in this study with the combination of GDM
plus periodontal disease had
ndash a 23-fold greater risk for developing adverse maternal outcomes than women with either GDM or periodontal disease alone
Fig 1
Gestational Diabetes Mellitus Periodontal Disease
Negative Maternal and Fetal Outcomes
Combined Effect
Periodontal Variable
Adverse pregnancy outcomes
n=130
No adverse pregnancy outcomes
n=176
P- value (Wilcoxon test)
Plaque index 056 (019) 053 (017) 008
Probing depth 28 (051) 27 (056) 001
Clinical attachment loss
063 (055) 062 (055) 084
Calculus (0-3) 044 (037) 039 (037) 017
Bleeding (0-3) 036 (030) 033 (031) 007
Case Control Comparison
Periodontal Variable
GDM + n=153
GDM ndash n=153
(P- value) (Wilcoxon
test)
Plaque index 055 (017) 053 (019) 026
Probing depth 28 (057) 27 (049) 008
Clinical attachment loss
066 (056) 058 (054) 021
Calculus (0-3) 044 (037) 039 (037) 020
Bleeding (0-3) 037 (031) 032 (030) 021
Case Control Comparison
Conclusions bull Probing pocket depth independent of GDM
status was a significant predictor of adverse pregnancy outcomes (p=001)
bull Bleeding on probing was related to adverse pregnancy outcomes (p=007)
bull GDM status was related to probing pocket depth (p=008)
Odds Ratios for Adverse Fetal Outcomes
Contrasts for PD and GDM status Odds Ratio 95 CI
PD+ GDM+ vs PD- GDM- 142 064 314
PD+ GDM+ vs PD- GDM+ 147 066 327
PD+ GDM+ vs PD+ GDM- 119 058 242
Multivariable logistic regression GEE adjusted for smoking and calculus Variables used for matching were not used as covariates in the GEE matched analysis regression
modeling These included age raceethnicity and gestational age at enrollment
Conclusion bull Women in this study with the combination of GDM
plus periodontal disease had
ndash no greater risk for adverse fetal outcomes than women with either GDM or periodontal disease alone
Conclusions bull Women in this study with the combination of GDM
plus periodontal disease had
ndash a 23-fold greater risk for developing adverse maternal outcomes than women with either GDM or periodontal disease alone bull Probing pocket depth independent of GDM status was a
significant predictor of adverse pregnancy outcomes (p=001)
bull Bleeding on probing was related to adverse pregnancy outcomes (p=007)
bull GDM status was related to probing pocket depth (p=008)
ndash no greater risk for adverse fetal outcomes than women with either GDM or periodontal disease alone
Exploring the possible biology of an oral-systemic link
ldquoOral health is integral to general healthrdquo
A ldquosilent epidemic of oral diseases is affecting our most vulnerable citizensrdquo
How could periodontal disease contribute to systemic
conditions
Defining periodontal disease
bull An inflammatory disease that is initiated by the
accumulation of Gram-negative bacteria around the
teeth and gums
Potential mechanisms
bull Dissemination of periodontal infection
bull Dissemination of periodontal inflammation
Is there evidence that periodontal bacteria play a major role
bull ldquoGuilt by associationrdquo
ndash Periodontal bacteria rarely found in systemic organs
ndash Case of fetal demise due to oral Fusobacterial infection extremely rare
ndash No cases of stroke or myocardial infarction due to periodontal infection
Letrsquos look at inflammation as a potential culprit
Inflammation
bull Initiates the host response to challenge
bull Brings immune cells and molecules to the site of challenge
bull A tightly regulated mechanism
bull When dysregulated leads to pathology
ndash Genetic (polymorphisms in gene structure)
ndash Environmental (smoking stress diet)
ndash Systemic (obesity type 2 diabetes hormonal)
Including
Periodontal disease
Periodontal disease and systemic disease
bull Risk indicator or risk factor
ndash Risk indicator ndash periodontal disease and the systemic condition share common etiologies
ndash Risk factor ndash oral infectioninflammation contributes to the genesis of the systemic condition Remove periodontal disease and the systemic condition improves
What is the evidence
bull Cross sectional studies
ndash periodontal disease may be a risk indicator for systemic inflammatory conditions in certain populations
ndash failed to show a causal effect suggesting that periodontal disease is not a risk factor for systemic disease
What is the answer
bull Periodontitis and systemic inflammatory conditions have complex etiologies
bull Influenced by
ndash Socio-economic status
ndash Lifestyle choicesbehaviors
bull Diet stress smoking drug abuse
ndash Genetics family history a good predictor
bull Infection
bull Inflammation
The answer may lie in complex interactions between multiple components of susceptibility This may make it very difficult to show a direct causal relationship between periodontal disease and systemic conditions
Thank you
KarenFNovakuthtmcedu
References Dasanayake AP1 Chhun N Tanner AC Craig RG Lee MJ Moore AF Norman RG J Dent Res 2008 Periodontal pathogens and gestational diabetes mellitus 2008 Apr87(4)328-33 Xiong X1 Elkind-Hirsch KE Vastardis S Delarosa RL Pridjian G Buekens P Periodontal disease is associated with gestational diabetes mellitus a case-control study J Periodontol 2009 Nov80(11)1742-9 Ruiz DR1 Romito GA Dib SA Periodontal disease in gestational and type 1 diabetes mellitus pregnant women Oral Dis 2011 Jul17(5)515-21 Xiong X Elkind-Hirsch KE Xie Y Delarosa R Maney P Pridjian G Buekens P Periodontal disease as a potential risk factor for the development of diabetes in women with a prior history of gestational diabetes mellitus J Public Health Dent 2013 Winter73(1)41-9 Michalowicz BS Hodges JS DiANgelis AJ Lupo VR Novak MJ Ferguson JE et al Treatment of periodontal disease and the risk of preterm birth N Engl J Med 2006 3551885-94 Offenbacher S Beck JD Jared HL Maaureilllo SM Mendoza LC Couper DJ et al Effects of periodontal therapy on rate or preterm delivery a randomized controlled trial Maternal Oral Therapy to Reduce Obstetric Risk (MOTOR) Investigators Obstet Gynecol 2009 114551-9 Committee on Health Care for Underserved Women Committee Opinion Oral health care during pregnancy and through the lifespan 2013 122417-422
Study 1 NHANES III Analysis
Novak KF Taylor G Ferguson JE and Novak MJ 2006 Periodontitis and Gestational Diabetes Mellitus Exploring the Link in NHANES III J Pub Health Dent 66163-168
Periodontal Disease and GDM bull 4244 women ages 20-59
ndash 113 had a history of GDM during pregnancy
bull Periodontal disease defined as one or more teeth with one or more sites with PDgt4mm LOA gt2mm and bleeding on probing
bull There was a trend for women with a history of GDM to have more periodontal disease than women without a history of GDM
Hypothesis Fig 1
Gestational Diabetes Mellitus Periodontal Disease
Negative Maternal and Fetal Outcomes
Combined Effect
Novak KF Taylor G Ferguson JE and Novak MJ 2006 Periodontitis and Gestational Diabetes Mellitus
Exploring the Link in NHANES III J Pub Health Dent 66163-168
Periodontal Disease and GDM bull Prior GDM higher pre-pregnancy BMI vaginal levels of Tannerella forsythia and C-
reactive protein were risk factors for developing GDM Periodontal disease was not statistically significant Dasanayakeet al 2008
ldquoNew Evidence of Periodontal Disease Leading to Gestational Diabetesrdquo
bull Further support for the hypothesis that there is an association between periodontal disease and GDM Xiong et al 2009
bull The presence of periodontal disease was significantly higher in women with either GDM or Type 2 diabetes during their pregnancy Age pregestational BMI and HbA1c) were related to clinical attachment loss in these two group Ruiz et al 2011
bull Women with both prior GDM and periodontal disease showed greater insulin resistance and altered Beta cell function potentially making them at greater risk for developing Type 2 diabetes Xiong et al 2012
Study 2 NIH Cross-Sectional Analysis
NIHNCRR Center of Biomedical Research Excellence P20 RR020145
University of Kentucky CR-DOC
Study Population
bull 306 matched pairs of pregnant women ndash Ages 16-45
ndash No history of type 1 or type 2 diabetes mellitus
ndash Minimum of 20 teeth
bull 153 with GDM 153 controls without GDM ndash Age raceethnicity and gestational age matched
bull Categorized by presenceabsence of periodontal disease (PD)
Data Collection bull Enrollment
ndash Consent and HIPAA authorization
ndash Medical and dental histories
ndash Comprehensive periodontal examination
bull Plaque index probing pocket depths clinical
attachment levels bleeding index calculus index
ndash Periodontitis (PD)
bull At least 4 teeth with PD gt4mm LOA gt2mm and
BOP
Data Collection
Laboratory samples
bull Serum ndash assessed by ELISA and Luminex
bull Subgingival plaque ndash biofilm microbiota assessed by qPCR
Data collection bull Post-delivery maternal and fetal outcomes
ndash Maternal pre-eclampsia premature labor premature rupture of membranes urinary tract infections chorioamnionitisfunisitis induction of labor operative vaginal deliveries or unplanned cesarean
Multivariable logistic regression GEE adjusted for smoking and calculus Variables used for matching were not used as covariates in the GEE matched analysis regression
modeling These included age raceethnicity and gestational age at enrollment
Conclusion bull Women in this study with the combination of GDM
plus periodontal disease had
ndash a 23-fold greater risk for developing adverse maternal outcomes than women with either GDM or periodontal disease alone
Fig 1
Gestational Diabetes Mellitus Periodontal Disease
Negative Maternal and Fetal Outcomes
Combined Effect
Periodontal Variable
Adverse pregnancy outcomes
n=130
No adverse pregnancy outcomes
n=176
P- value (Wilcoxon test)
Plaque index 056 (019) 053 (017) 008
Probing depth 28 (051) 27 (056) 001
Clinical attachment loss
063 (055) 062 (055) 084
Calculus (0-3) 044 (037) 039 (037) 017
Bleeding (0-3) 036 (030) 033 (031) 007
Case Control Comparison
Periodontal Variable
GDM + n=153
GDM ndash n=153
(P- value) (Wilcoxon
test)
Plaque index 055 (017) 053 (019) 026
Probing depth 28 (057) 27 (049) 008
Clinical attachment loss
066 (056) 058 (054) 021
Calculus (0-3) 044 (037) 039 (037) 020
Bleeding (0-3) 037 (031) 032 (030) 021
Case Control Comparison
Conclusions bull Probing pocket depth independent of GDM
status was a significant predictor of adverse pregnancy outcomes (p=001)
bull Bleeding on probing was related to adverse pregnancy outcomes (p=007)
bull GDM status was related to probing pocket depth (p=008)
Odds Ratios for Adverse Fetal Outcomes
Contrasts for PD and GDM status Odds Ratio 95 CI
PD+ GDM+ vs PD- GDM- 142 064 314
PD+ GDM+ vs PD- GDM+ 147 066 327
PD+ GDM+ vs PD+ GDM- 119 058 242
Multivariable logistic regression GEE adjusted for smoking and calculus Variables used for matching were not used as covariates in the GEE matched analysis regression
modeling These included age raceethnicity and gestational age at enrollment
Conclusion bull Women in this study with the combination of GDM
plus periodontal disease had
ndash no greater risk for adverse fetal outcomes than women with either GDM or periodontal disease alone
Conclusions bull Women in this study with the combination of GDM
plus periodontal disease had
ndash a 23-fold greater risk for developing adverse maternal outcomes than women with either GDM or periodontal disease alone bull Probing pocket depth independent of GDM status was a
significant predictor of adverse pregnancy outcomes (p=001)
bull Bleeding on probing was related to adverse pregnancy outcomes (p=007)
bull GDM status was related to probing pocket depth (p=008)
ndash no greater risk for adverse fetal outcomes than women with either GDM or periodontal disease alone
Exploring the possible biology of an oral-systemic link
ldquoOral health is integral to general healthrdquo
A ldquosilent epidemic of oral diseases is affecting our most vulnerable citizensrdquo
How could periodontal disease contribute to systemic
conditions
Defining periodontal disease
bull An inflammatory disease that is initiated by the
accumulation of Gram-negative bacteria around the
teeth and gums
Potential mechanisms
bull Dissemination of periodontal infection
bull Dissemination of periodontal inflammation
Is there evidence that periodontal bacteria play a major role
bull ldquoGuilt by associationrdquo
ndash Periodontal bacteria rarely found in systemic organs
ndash Case of fetal demise due to oral Fusobacterial infection extremely rare
ndash No cases of stroke or myocardial infarction due to periodontal infection
Letrsquos look at inflammation as a potential culprit
Inflammation
bull Initiates the host response to challenge
bull Brings immune cells and molecules to the site of challenge
bull A tightly regulated mechanism
bull When dysregulated leads to pathology
ndash Genetic (polymorphisms in gene structure)
ndash Environmental (smoking stress diet)
ndash Systemic (obesity type 2 diabetes hormonal)
Including
Periodontal disease
Periodontal disease and systemic disease
bull Risk indicator or risk factor
ndash Risk indicator ndash periodontal disease and the systemic condition share common etiologies
ndash Risk factor ndash oral infectioninflammation contributes to the genesis of the systemic condition Remove periodontal disease and the systemic condition improves
What is the evidence
bull Cross sectional studies
ndash periodontal disease may be a risk indicator for systemic inflammatory conditions in certain populations
ndash failed to show a causal effect suggesting that periodontal disease is not a risk factor for systemic disease
What is the answer
bull Periodontitis and systemic inflammatory conditions have complex etiologies
bull Influenced by
ndash Socio-economic status
ndash Lifestyle choicesbehaviors
bull Diet stress smoking drug abuse
ndash Genetics family history a good predictor
bull Infection
bull Inflammation
The answer may lie in complex interactions between multiple components of susceptibility This may make it very difficult to show a direct causal relationship between periodontal disease and systemic conditions
Thank you
KarenFNovakuthtmcedu
References Dasanayake AP1 Chhun N Tanner AC Craig RG Lee MJ Moore AF Norman RG J Dent Res 2008 Periodontal pathogens and gestational diabetes mellitus 2008 Apr87(4)328-33 Xiong X1 Elkind-Hirsch KE Vastardis S Delarosa RL Pridjian G Buekens P Periodontal disease is associated with gestational diabetes mellitus a case-control study J Periodontol 2009 Nov80(11)1742-9 Ruiz DR1 Romito GA Dib SA Periodontal disease in gestational and type 1 diabetes mellitus pregnant women Oral Dis 2011 Jul17(5)515-21 Xiong X Elkind-Hirsch KE Xie Y Delarosa R Maney P Pridjian G Buekens P Periodontal disease as a potential risk factor for the development of diabetes in women with a prior history of gestational diabetes mellitus J Public Health Dent 2013 Winter73(1)41-9 Michalowicz BS Hodges JS DiANgelis AJ Lupo VR Novak MJ Ferguson JE et al Treatment of periodontal disease and the risk of preterm birth N Engl J Med 2006 3551885-94 Offenbacher S Beck JD Jared HL Maaureilllo SM Mendoza LC Couper DJ et al Effects of periodontal therapy on rate or preterm delivery a randomized controlled trial Maternal Oral Therapy to Reduce Obstetric Risk (MOTOR) Investigators Obstet Gynecol 2009 114551-9 Committee on Health Care for Underserved Women Committee Opinion Oral health care during pregnancy and through the lifespan 2013 122417-422
Periodontal Disease and GDM bull 4244 women ages 20-59
ndash 113 had a history of GDM during pregnancy
bull Periodontal disease defined as one or more teeth with one or more sites with PDgt4mm LOA gt2mm and bleeding on probing
bull There was a trend for women with a history of GDM to have more periodontal disease than women without a history of GDM
Hypothesis Fig 1
Gestational Diabetes Mellitus Periodontal Disease
Negative Maternal and Fetal Outcomes
Combined Effect
Novak KF Taylor G Ferguson JE and Novak MJ 2006 Periodontitis and Gestational Diabetes Mellitus
Exploring the Link in NHANES III J Pub Health Dent 66163-168
Periodontal Disease and GDM bull Prior GDM higher pre-pregnancy BMI vaginal levels of Tannerella forsythia and C-
reactive protein were risk factors for developing GDM Periodontal disease was not statistically significant Dasanayakeet al 2008
ldquoNew Evidence of Periodontal Disease Leading to Gestational Diabetesrdquo
bull Further support for the hypothesis that there is an association between periodontal disease and GDM Xiong et al 2009
bull The presence of periodontal disease was significantly higher in women with either GDM or Type 2 diabetes during their pregnancy Age pregestational BMI and HbA1c) were related to clinical attachment loss in these two group Ruiz et al 2011
bull Women with both prior GDM and periodontal disease showed greater insulin resistance and altered Beta cell function potentially making them at greater risk for developing Type 2 diabetes Xiong et al 2012
Study 2 NIH Cross-Sectional Analysis
NIHNCRR Center of Biomedical Research Excellence P20 RR020145
University of Kentucky CR-DOC
Study Population
bull 306 matched pairs of pregnant women ndash Ages 16-45
ndash No history of type 1 or type 2 diabetes mellitus
ndash Minimum of 20 teeth
bull 153 with GDM 153 controls without GDM ndash Age raceethnicity and gestational age matched
bull Categorized by presenceabsence of periodontal disease (PD)
Data Collection bull Enrollment
ndash Consent and HIPAA authorization
ndash Medical and dental histories
ndash Comprehensive periodontal examination
bull Plaque index probing pocket depths clinical
attachment levels bleeding index calculus index
ndash Periodontitis (PD)
bull At least 4 teeth with PD gt4mm LOA gt2mm and
BOP
Data Collection
Laboratory samples
bull Serum ndash assessed by ELISA and Luminex
bull Subgingival plaque ndash biofilm microbiota assessed by qPCR
Data collection bull Post-delivery maternal and fetal outcomes
ndash Maternal pre-eclampsia premature labor premature rupture of membranes urinary tract infections chorioamnionitisfunisitis induction of labor operative vaginal deliveries or unplanned cesarean
Multivariable logistic regression GEE adjusted for smoking and calculus Variables used for matching were not used as covariates in the GEE matched analysis regression
modeling These included age raceethnicity and gestational age at enrollment
Conclusion bull Women in this study with the combination of GDM
plus periodontal disease had
ndash a 23-fold greater risk for developing adverse maternal outcomes than women with either GDM or periodontal disease alone
Fig 1
Gestational Diabetes Mellitus Periodontal Disease
Negative Maternal and Fetal Outcomes
Combined Effect
Periodontal Variable
Adverse pregnancy outcomes
n=130
No adverse pregnancy outcomes
n=176
P- value (Wilcoxon test)
Plaque index 056 (019) 053 (017) 008
Probing depth 28 (051) 27 (056) 001
Clinical attachment loss
063 (055) 062 (055) 084
Calculus (0-3) 044 (037) 039 (037) 017
Bleeding (0-3) 036 (030) 033 (031) 007
Case Control Comparison
Periodontal Variable
GDM + n=153
GDM ndash n=153
(P- value) (Wilcoxon
test)
Plaque index 055 (017) 053 (019) 026
Probing depth 28 (057) 27 (049) 008
Clinical attachment loss
066 (056) 058 (054) 021
Calculus (0-3) 044 (037) 039 (037) 020
Bleeding (0-3) 037 (031) 032 (030) 021
Case Control Comparison
Conclusions bull Probing pocket depth independent of GDM
status was a significant predictor of adverse pregnancy outcomes (p=001)
bull Bleeding on probing was related to adverse pregnancy outcomes (p=007)
bull GDM status was related to probing pocket depth (p=008)
Odds Ratios for Adverse Fetal Outcomes
Contrasts for PD and GDM status Odds Ratio 95 CI
PD+ GDM+ vs PD- GDM- 142 064 314
PD+ GDM+ vs PD- GDM+ 147 066 327
PD+ GDM+ vs PD+ GDM- 119 058 242
Multivariable logistic regression GEE adjusted for smoking and calculus Variables used for matching were not used as covariates in the GEE matched analysis regression
modeling These included age raceethnicity and gestational age at enrollment
Conclusion bull Women in this study with the combination of GDM
plus periodontal disease had
ndash no greater risk for adverse fetal outcomes than women with either GDM or periodontal disease alone
Conclusions bull Women in this study with the combination of GDM
plus periodontal disease had
ndash a 23-fold greater risk for developing adverse maternal outcomes than women with either GDM or periodontal disease alone bull Probing pocket depth independent of GDM status was a
significant predictor of adverse pregnancy outcomes (p=001)
bull Bleeding on probing was related to adverse pregnancy outcomes (p=007)
bull GDM status was related to probing pocket depth (p=008)
ndash no greater risk for adverse fetal outcomes than women with either GDM or periodontal disease alone
Exploring the possible biology of an oral-systemic link
ldquoOral health is integral to general healthrdquo
A ldquosilent epidemic of oral diseases is affecting our most vulnerable citizensrdquo
How could periodontal disease contribute to systemic
conditions
Defining periodontal disease
bull An inflammatory disease that is initiated by the
accumulation of Gram-negative bacteria around the
teeth and gums
Potential mechanisms
bull Dissemination of periodontal infection
bull Dissemination of periodontal inflammation
Is there evidence that periodontal bacteria play a major role
bull ldquoGuilt by associationrdquo
ndash Periodontal bacteria rarely found in systemic organs
ndash Case of fetal demise due to oral Fusobacterial infection extremely rare
ndash No cases of stroke or myocardial infarction due to periodontal infection
Letrsquos look at inflammation as a potential culprit
Inflammation
bull Initiates the host response to challenge
bull Brings immune cells and molecules to the site of challenge
bull A tightly regulated mechanism
bull When dysregulated leads to pathology
ndash Genetic (polymorphisms in gene structure)
ndash Environmental (smoking stress diet)
ndash Systemic (obesity type 2 diabetes hormonal)
Including
Periodontal disease
Periodontal disease and systemic disease
bull Risk indicator or risk factor
ndash Risk indicator ndash periodontal disease and the systemic condition share common etiologies
ndash Risk factor ndash oral infectioninflammation contributes to the genesis of the systemic condition Remove periodontal disease and the systemic condition improves
What is the evidence
bull Cross sectional studies
ndash periodontal disease may be a risk indicator for systemic inflammatory conditions in certain populations
ndash failed to show a causal effect suggesting that periodontal disease is not a risk factor for systemic disease
What is the answer
bull Periodontitis and systemic inflammatory conditions have complex etiologies
bull Influenced by
ndash Socio-economic status
ndash Lifestyle choicesbehaviors
bull Diet stress smoking drug abuse
ndash Genetics family history a good predictor
bull Infection
bull Inflammation
The answer may lie in complex interactions between multiple components of susceptibility This may make it very difficult to show a direct causal relationship between periodontal disease and systemic conditions
Thank you
KarenFNovakuthtmcedu
References Dasanayake AP1 Chhun N Tanner AC Craig RG Lee MJ Moore AF Norman RG J Dent Res 2008 Periodontal pathogens and gestational diabetes mellitus 2008 Apr87(4)328-33 Xiong X1 Elkind-Hirsch KE Vastardis S Delarosa RL Pridjian G Buekens P Periodontal disease is associated with gestational diabetes mellitus a case-control study J Periodontol 2009 Nov80(11)1742-9 Ruiz DR1 Romito GA Dib SA Periodontal disease in gestational and type 1 diabetes mellitus pregnant women Oral Dis 2011 Jul17(5)515-21 Xiong X Elkind-Hirsch KE Xie Y Delarosa R Maney P Pridjian G Buekens P Periodontal disease as a potential risk factor for the development of diabetes in women with a prior history of gestational diabetes mellitus J Public Health Dent 2013 Winter73(1)41-9 Michalowicz BS Hodges JS DiANgelis AJ Lupo VR Novak MJ Ferguson JE et al Treatment of periodontal disease and the risk of preterm birth N Engl J Med 2006 3551885-94 Offenbacher S Beck JD Jared HL Maaureilllo SM Mendoza LC Couper DJ et al Effects of periodontal therapy on rate or preterm delivery a randomized controlled trial Maternal Oral Therapy to Reduce Obstetric Risk (MOTOR) Investigators Obstet Gynecol 2009 114551-9 Committee on Health Care for Underserved Women Committee Opinion Oral health care during pregnancy and through the lifespan 2013 122417-422
Hypothesis Fig 1
Gestational Diabetes Mellitus Periodontal Disease
Negative Maternal and Fetal Outcomes
Combined Effect
Novak KF Taylor G Ferguson JE and Novak MJ 2006 Periodontitis and Gestational Diabetes Mellitus
Exploring the Link in NHANES III J Pub Health Dent 66163-168
Periodontal Disease and GDM bull Prior GDM higher pre-pregnancy BMI vaginal levels of Tannerella forsythia and C-
reactive protein were risk factors for developing GDM Periodontal disease was not statistically significant Dasanayakeet al 2008
ldquoNew Evidence of Periodontal Disease Leading to Gestational Diabetesrdquo
bull Further support for the hypothesis that there is an association between periodontal disease and GDM Xiong et al 2009
bull The presence of periodontal disease was significantly higher in women with either GDM or Type 2 diabetes during their pregnancy Age pregestational BMI and HbA1c) were related to clinical attachment loss in these two group Ruiz et al 2011
bull Women with both prior GDM and periodontal disease showed greater insulin resistance and altered Beta cell function potentially making them at greater risk for developing Type 2 diabetes Xiong et al 2012
Study 2 NIH Cross-Sectional Analysis
NIHNCRR Center of Biomedical Research Excellence P20 RR020145
University of Kentucky CR-DOC
Study Population
bull 306 matched pairs of pregnant women ndash Ages 16-45
ndash No history of type 1 or type 2 diabetes mellitus
ndash Minimum of 20 teeth
bull 153 with GDM 153 controls without GDM ndash Age raceethnicity and gestational age matched
bull Categorized by presenceabsence of periodontal disease (PD)
Data Collection bull Enrollment
ndash Consent and HIPAA authorization
ndash Medical and dental histories
ndash Comprehensive periodontal examination
bull Plaque index probing pocket depths clinical
attachment levels bleeding index calculus index
ndash Periodontitis (PD)
bull At least 4 teeth with PD gt4mm LOA gt2mm and
BOP
Data Collection
Laboratory samples
bull Serum ndash assessed by ELISA and Luminex
bull Subgingival plaque ndash biofilm microbiota assessed by qPCR
Data collection bull Post-delivery maternal and fetal outcomes
ndash Maternal pre-eclampsia premature labor premature rupture of membranes urinary tract infections chorioamnionitisfunisitis induction of labor operative vaginal deliveries or unplanned cesarean
Multivariable logistic regression GEE adjusted for smoking and calculus Variables used for matching were not used as covariates in the GEE matched analysis regression
modeling These included age raceethnicity and gestational age at enrollment
Conclusion bull Women in this study with the combination of GDM
plus periodontal disease had
ndash a 23-fold greater risk for developing adverse maternal outcomes than women with either GDM or periodontal disease alone
Fig 1
Gestational Diabetes Mellitus Periodontal Disease
Negative Maternal and Fetal Outcomes
Combined Effect
Periodontal Variable
Adverse pregnancy outcomes
n=130
No adverse pregnancy outcomes
n=176
P- value (Wilcoxon test)
Plaque index 056 (019) 053 (017) 008
Probing depth 28 (051) 27 (056) 001
Clinical attachment loss
063 (055) 062 (055) 084
Calculus (0-3) 044 (037) 039 (037) 017
Bleeding (0-3) 036 (030) 033 (031) 007
Case Control Comparison
Periodontal Variable
GDM + n=153
GDM ndash n=153
(P- value) (Wilcoxon
test)
Plaque index 055 (017) 053 (019) 026
Probing depth 28 (057) 27 (049) 008
Clinical attachment loss
066 (056) 058 (054) 021
Calculus (0-3) 044 (037) 039 (037) 020
Bleeding (0-3) 037 (031) 032 (030) 021
Case Control Comparison
Conclusions bull Probing pocket depth independent of GDM
status was a significant predictor of adverse pregnancy outcomes (p=001)
bull Bleeding on probing was related to adverse pregnancy outcomes (p=007)
bull GDM status was related to probing pocket depth (p=008)
Odds Ratios for Adverse Fetal Outcomes
Contrasts for PD and GDM status Odds Ratio 95 CI
PD+ GDM+ vs PD- GDM- 142 064 314
PD+ GDM+ vs PD- GDM+ 147 066 327
PD+ GDM+ vs PD+ GDM- 119 058 242
Multivariable logistic regression GEE adjusted for smoking and calculus Variables used for matching were not used as covariates in the GEE matched analysis regression
modeling These included age raceethnicity and gestational age at enrollment
Conclusion bull Women in this study with the combination of GDM
plus periodontal disease had
ndash no greater risk for adverse fetal outcomes than women with either GDM or periodontal disease alone
Conclusions bull Women in this study with the combination of GDM
plus periodontal disease had
ndash a 23-fold greater risk for developing adverse maternal outcomes than women with either GDM or periodontal disease alone bull Probing pocket depth independent of GDM status was a
significant predictor of adverse pregnancy outcomes (p=001)
bull Bleeding on probing was related to adverse pregnancy outcomes (p=007)
bull GDM status was related to probing pocket depth (p=008)
ndash no greater risk for adverse fetal outcomes than women with either GDM or periodontal disease alone
Exploring the possible biology of an oral-systemic link
ldquoOral health is integral to general healthrdquo
A ldquosilent epidemic of oral diseases is affecting our most vulnerable citizensrdquo
How could periodontal disease contribute to systemic
conditions
Defining periodontal disease
bull An inflammatory disease that is initiated by the
accumulation of Gram-negative bacteria around the
teeth and gums
Potential mechanisms
bull Dissemination of periodontal infection
bull Dissemination of periodontal inflammation
Is there evidence that periodontal bacteria play a major role
bull ldquoGuilt by associationrdquo
ndash Periodontal bacteria rarely found in systemic organs
ndash Case of fetal demise due to oral Fusobacterial infection extremely rare
ndash No cases of stroke or myocardial infarction due to periodontal infection
Letrsquos look at inflammation as a potential culprit
Inflammation
bull Initiates the host response to challenge
bull Brings immune cells and molecules to the site of challenge
bull A tightly regulated mechanism
bull When dysregulated leads to pathology
ndash Genetic (polymorphisms in gene structure)
ndash Environmental (smoking stress diet)
ndash Systemic (obesity type 2 diabetes hormonal)
Including
Periodontal disease
Periodontal disease and systemic disease
bull Risk indicator or risk factor
ndash Risk indicator ndash periodontal disease and the systemic condition share common etiologies
ndash Risk factor ndash oral infectioninflammation contributes to the genesis of the systemic condition Remove periodontal disease and the systemic condition improves
What is the evidence
bull Cross sectional studies
ndash periodontal disease may be a risk indicator for systemic inflammatory conditions in certain populations
ndash failed to show a causal effect suggesting that periodontal disease is not a risk factor for systemic disease
What is the answer
bull Periodontitis and systemic inflammatory conditions have complex etiologies
bull Influenced by
ndash Socio-economic status
ndash Lifestyle choicesbehaviors
bull Diet stress smoking drug abuse
ndash Genetics family history a good predictor
bull Infection
bull Inflammation
The answer may lie in complex interactions between multiple components of susceptibility This may make it very difficult to show a direct causal relationship between periodontal disease and systemic conditions
Thank you
KarenFNovakuthtmcedu
References Dasanayake AP1 Chhun N Tanner AC Craig RG Lee MJ Moore AF Norman RG J Dent Res 2008 Periodontal pathogens and gestational diabetes mellitus 2008 Apr87(4)328-33 Xiong X1 Elkind-Hirsch KE Vastardis S Delarosa RL Pridjian G Buekens P Periodontal disease is associated with gestational diabetes mellitus a case-control study J Periodontol 2009 Nov80(11)1742-9 Ruiz DR1 Romito GA Dib SA Periodontal disease in gestational and type 1 diabetes mellitus pregnant women Oral Dis 2011 Jul17(5)515-21 Xiong X Elkind-Hirsch KE Xie Y Delarosa R Maney P Pridjian G Buekens P Periodontal disease as a potential risk factor for the development of diabetes in women with a prior history of gestational diabetes mellitus J Public Health Dent 2013 Winter73(1)41-9 Michalowicz BS Hodges JS DiANgelis AJ Lupo VR Novak MJ Ferguson JE et al Treatment of periodontal disease and the risk of preterm birth N Engl J Med 2006 3551885-94 Offenbacher S Beck JD Jared HL Maaureilllo SM Mendoza LC Couper DJ et al Effects of periodontal therapy on rate or preterm delivery a randomized controlled trial Maternal Oral Therapy to Reduce Obstetric Risk (MOTOR) Investigators Obstet Gynecol 2009 114551-9 Committee on Health Care for Underserved Women Committee Opinion Oral health care during pregnancy and through the lifespan 2013 122417-422
Periodontal Disease and GDM bull Prior GDM higher pre-pregnancy BMI vaginal levels of Tannerella forsythia and C-
reactive protein were risk factors for developing GDM Periodontal disease was not statistically significant Dasanayakeet al 2008
ldquoNew Evidence of Periodontal Disease Leading to Gestational Diabetesrdquo
bull Further support for the hypothesis that there is an association between periodontal disease and GDM Xiong et al 2009
bull The presence of periodontal disease was significantly higher in women with either GDM or Type 2 diabetes during their pregnancy Age pregestational BMI and HbA1c) were related to clinical attachment loss in these two group Ruiz et al 2011
bull Women with both prior GDM and periodontal disease showed greater insulin resistance and altered Beta cell function potentially making them at greater risk for developing Type 2 diabetes Xiong et al 2012
Study 2 NIH Cross-Sectional Analysis
NIHNCRR Center of Biomedical Research Excellence P20 RR020145
University of Kentucky CR-DOC
Study Population
bull 306 matched pairs of pregnant women ndash Ages 16-45
ndash No history of type 1 or type 2 diabetes mellitus
ndash Minimum of 20 teeth
bull 153 with GDM 153 controls without GDM ndash Age raceethnicity and gestational age matched
bull Categorized by presenceabsence of periodontal disease (PD)
Data Collection bull Enrollment
ndash Consent and HIPAA authorization
ndash Medical and dental histories
ndash Comprehensive periodontal examination
bull Plaque index probing pocket depths clinical
attachment levels bleeding index calculus index
ndash Periodontitis (PD)
bull At least 4 teeth with PD gt4mm LOA gt2mm and
BOP
Data Collection
Laboratory samples
bull Serum ndash assessed by ELISA and Luminex
bull Subgingival plaque ndash biofilm microbiota assessed by qPCR
Data collection bull Post-delivery maternal and fetal outcomes
ndash Maternal pre-eclampsia premature labor premature rupture of membranes urinary tract infections chorioamnionitisfunisitis induction of labor operative vaginal deliveries or unplanned cesarean
Multivariable logistic regression GEE adjusted for smoking and calculus Variables used for matching were not used as covariates in the GEE matched analysis regression
modeling These included age raceethnicity and gestational age at enrollment
Conclusion bull Women in this study with the combination of GDM
plus periodontal disease had
ndash a 23-fold greater risk for developing adverse maternal outcomes than women with either GDM or periodontal disease alone
Fig 1
Gestational Diabetes Mellitus Periodontal Disease
Negative Maternal and Fetal Outcomes
Combined Effect
Periodontal Variable
Adverse pregnancy outcomes
n=130
No adverse pregnancy outcomes
n=176
P- value (Wilcoxon test)
Plaque index 056 (019) 053 (017) 008
Probing depth 28 (051) 27 (056) 001
Clinical attachment loss
063 (055) 062 (055) 084
Calculus (0-3) 044 (037) 039 (037) 017
Bleeding (0-3) 036 (030) 033 (031) 007
Case Control Comparison
Periodontal Variable
GDM + n=153
GDM ndash n=153
(P- value) (Wilcoxon
test)
Plaque index 055 (017) 053 (019) 026
Probing depth 28 (057) 27 (049) 008
Clinical attachment loss
066 (056) 058 (054) 021
Calculus (0-3) 044 (037) 039 (037) 020
Bleeding (0-3) 037 (031) 032 (030) 021
Case Control Comparison
Conclusions bull Probing pocket depth independent of GDM
status was a significant predictor of adverse pregnancy outcomes (p=001)
bull Bleeding on probing was related to adverse pregnancy outcomes (p=007)
bull GDM status was related to probing pocket depth (p=008)
Odds Ratios for Adverse Fetal Outcomes
Contrasts for PD and GDM status Odds Ratio 95 CI
PD+ GDM+ vs PD- GDM- 142 064 314
PD+ GDM+ vs PD- GDM+ 147 066 327
PD+ GDM+ vs PD+ GDM- 119 058 242
Multivariable logistic regression GEE adjusted for smoking and calculus Variables used for matching were not used as covariates in the GEE matched analysis regression
modeling These included age raceethnicity and gestational age at enrollment
Conclusion bull Women in this study with the combination of GDM
plus periodontal disease had
ndash no greater risk for adverse fetal outcomes than women with either GDM or periodontal disease alone
Conclusions bull Women in this study with the combination of GDM
plus periodontal disease had
ndash a 23-fold greater risk for developing adverse maternal outcomes than women with either GDM or periodontal disease alone bull Probing pocket depth independent of GDM status was a
significant predictor of adverse pregnancy outcomes (p=001)
bull Bleeding on probing was related to adverse pregnancy outcomes (p=007)
bull GDM status was related to probing pocket depth (p=008)
ndash no greater risk for adverse fetal outcomes than women with either GDM or periodontal disease alone
Exploring the possible biology of an oral-systemic link
ldquoOral health is integral to general healthrdquo
A ldquosilent epidemic of oral diseases is affecting our most vulnerable citizensrdquo
How could periodontal disease contribute to systemic
conditions
Defining periodontal disease
bull An inflammatory disease that is initiated by the
accumulation of Gram-negative bacteria around the
teeth and gums
Potential mechanisms
bull Dissemination of periodontal infection
bull Dissemination of periodontal inflammation
Is there evidence that periodontal bacteria play a major role
bull ldquoGuilt by associationrdquo
ndash Periodontal bacteria rarely found in systemic organs
ndash Case of fetal demise due to oral Fusobacterial infection extremely rare
ndash No cases of stroke or myocardial infarction due to periodontal infection
Letrsquos look at inflammation as a potential culprit
Inflammation
bull Initiates the host response to challenge
bull Brings immune cells and molecules to the site of challenge
bull A tightly regulated mechanism
bull When dysregulated leads to pathology
ndash Genetic (polymorphisms in gene structure)
ndash Environmental (smoking stress diet)
ndash Systemic (obesity type 2 diabetes hormonal)
Including
Periodontal disease
Periodontal disease and systemic disease
bull Risk indicator or risk factor
ndash Risk indicator ndash periodontal disease and the systemic condition share common etiologies
ndash Risk factor ndash oral infectioninflammation contributes to the genesis of the systemic condition Remove periodontal disease and the systemic condition improves
What is the evidence
bull Cross sectional studies
ndash periodontal disease may be a risk indicator for systemic inflammatory conditions in certain populations
ndash failed to show a causal effect suggesting that periodontal disease is not a risk factor for systemic disease
What is the answer
bull Periodontitis and systemic inflammatory conditions have complex etiologies
bull Influenced by
ndash Socio-economic status
ndash Lifestyle choicesbehaviors
bull Diet stress smoking drug abuse
ndash Genetics family history a good predictor
bull Infection
bull Inflammation
The answer may lie in complex interactions between multiple components of susceptibility This may make it very difficult to show a direct causal relationship between periodontal disease and systemic conditions
Thank you
KarenFNovakuthtmcedu
References Dasanayake AP1 Chhun N Tanner AC Craig RG Lee MJ Moore AF Norman RG J Dent Res 2008 Periodontal pathogens and gestational diabetes mellitus 2008 Apr87(4)328-33 Xiong X1 Elkind-Hirsch KE Vastardis S Delarosa RL Pridjian G Buekens P Periodontal disease is associated with gestational diabetes mellitus a case-control study J Periodontol 2009 Nov80(11)1742-9 Ruiz DR1 Romito GA Dib SA Periodontal disease in gestational and type 1 diabetes mellitus pregnant women Oral Dis 2011 Jul17(5)515-21 Xiong X Elkind-Hirsch KE Xie Y Delarosa R Maney P Pridjian G Buekens P Periodontal disease as a potential risk factor for the development of diabetes in women with a prior history of gestational diabetes mellitus J Public Health Dent 2013 Winter73(1)41-9 Michalowicz BS Hodges JS DiANgelis AJ Lupo VR Novak MJ Ferguson JE et al Treatment of periodontal disease and the risk of preterm birth N Engl J Med 2006 3551885-94 Offenbacher S Beck JD Jared HL Maaureilllo SM Mendoza LC Couper DJ et al Effects of periodontal therapy on rate or preterm delivery a randomized controlled trial Maternal Oral Therapy to Reduce Obstetric Risk (MOTOR) Investigators Obstet Gynecol 2009 114551-9 Committee on Health Care for Underserved Women Committee Opinion Oral health care during pregnancy and through the lifespan 2013 122417-422
Study 2 NIH Cross-Sectional Analysis
NIHNCRR Center of Biomedical Research Excellence P20 RR020145
University of Kentucky CR-DOC
Study Population
bull 306 matched pairs of pregnant women ndash Ages 16-45
ndash No history of type 1 or type 2 diabetes mellitus
ndash Minimum of 20 teeth
bull 153 with GDM 153 controls without GDM ndash Age raceethnicity and gestational age matched
bull Categorized by presenceabsence of periodontal disease (PD)
Data Collection bull Enrollment
ndash Consent and HIPAA authorization
ndash Medical and dental histories
ndash Comprehensive periodontal examination
bull Plaque index probing pocket depths clinical
attachment levels bleeding index calculus index
ndash Periodontitis (PD)
bull At least 4 teeth with PD gt4mm LOA gt2mm and
BOP
Data Collection
Laboratory samples
bull Serum ndash assessed by ELISA and Luminex
bull Subgingival plaque ndash biofilm microbiota assessed by qPCR
Data collection bull Post-delivery maternal and fetal outcomes
ndash Maternal pre-eclampsia premature labor premature rupture of membranes urinary tract infections chorioamnionitisfunisitis induction of labor operative vaginal deliveries or unplanned cesarean
Multivariable logistic regression GEE adjusted for smoking and calculus Variables used for matching were not used as covariates in the GEE matched analysis regression
modeling These included age raceethnicity and gestational age at enrollment
Conclusion bull Women in this study with the combination of GDM
plus periodontal disease had
ndash a 23-fold greater risk for developing adverse maternal outcomes than women with either GDM or periodontal disease alone
Fig 1
Gestational Diabetes Mellitus Periodontal Disease
Negative Maternal and Fetal Outcomes
Combined Effect
Periodontal Variable
Adverse pregnancy outcomes
n=130
No adverse pregnancy outcomes
n=176
P- value (Wilcoxon test)
Plaque index 056 (019) 053 (017) 008
Probing depth 28 (051) 27 (056) 001
Clinical attachment loss
063 (055) 062 (055) 084
Calculus (0-3) 044 (037) 039 (037) 017
Bleeding (0-3) 036 (030) 033 (031) 007
Case Control Comparison
Periodontal Variable
GDM + n=153
GDM ndash n=153
(P- value) (Wilcoxon
test)
Plaque index 055 (017) 053 (019) 026
Probing depth 28 (057) 27 (049) 008
Clinical attachment loss
066 (056) 058 (054) 021
Calculus (0-3) 044 (037) 039 (037) 020
Bleeding (0-3) 037 (031) 032 (030) 021
Case Control Comparison
Conclusions bull Probing pocket depth independent of GDM
status was a significant predictor of adverse pregnancy outcomes (p=001)
bull Bleeding on probing was related to adverse pregnancy outcomes (p=007)
bull GDM status was related to probing pocket depth (p=008)
Odds Ratios for Adverse Fetal Outcomes
Contrasts for PD and GDM status Odds Ratio 95 CI
PD+ GDM+ vs PD- GDM- 142 064 314
PD+ GDM+ vs PD- GDM+ 147 066 327
PD+ GDM+ vs PD+ GDM- 119 058 242
Multivariable logistic regression GEE adjusted for smoking and calculus Variables used for matching were not used as covariates in the GEE matched analysis regression
modeling These included age raceethnicity and gestational age at enrollment
Conclusion bull Women in this study with the combination of GDM
plus periodontal disease had
ndash no greater risk for adverse fetal outcomes than women with either GDM or periodontal disease alone
Conclusions bull Women in this study with the combination of GDM
plus periodontal disease had
ndash a 23-fold greater risk for developing adverse maternal outcomes than women with either GDM or periodontal disease alone bull Probing pocket depth independent of GDM status was a
significant predictor of adverse pregnancy outcomes (p=001)
bull Bleeding on probing was related to adverse pregnancy outcomes (p=007)
bull GDM status was related to probing pocket depth (p=008)
ndash no greater risk for adverse fetal outcomes than women with either GDM or periodontal disease alone
Exploring the possible biology of an oral-systemic link
ldquoOral health is integral to general healthrdquo
A ldquosilent epidemic of oral diseases is affecting our most vulnerable citizensrdquo
How could periodontal disease contribute to systemic
conditions
Defining periodontal disease
bull An inflammatory disease that is initiated by the
accumulation of Gram-negative bacteria around the
teeth and gums
Potential mechanisms
bull Dissemination of periodontal infection
bull Dissemination of periodontal inflammation
Is there evidence that periodontal bacteria play a major role
bull ldquoGuilt by associationrdquo
ndash Periodontal bacteria rarely found in systemic organs
ndash Case of fetal demise due to oral Fusobacterial infection extremely rare
ndash No cases of stroke or myocardial infarction due to periodontal infection
Letrsquos look at inflammation as a potential culprit
Inflammation
bull Initiates the host response to challenge
bull Brings immune cells and molecules to the site of challenge
bull A tightly regulated mechanism
bull When dysregulated leads to pathology
ndash Genetic (polymorphisms in gene structure)
ndash Environmental (smoking stress diet)
ndash Systemic (obesity type 2 diabetes hormonal)
Including
Periodontal disease
Periodontal disease and systemic disease
bull Risk indicator or risk factor
ndash Risk indicator ndash periodontal disease and the systemic condition share common etiologies
ndash Risk factor ndash oral infectioninflammation contributes to the genesis of the systemic condition Remove periodontal disease and the systemic condition improves
What is the evidence
bull Cross sectional studies
ndash periodontal disease may be a risk indicator for systemic inflammatory conditions in certain populations
ndash failed to show a causal effect suggesting that periodontal disease is not a risk factor for systemic disease
What is the answer
bull Periodontitis and systemic inflammatory conditions have complex etiologies
bull Influenced by
ndash Socio-economic status
ndash Lifestyle choicesbehaviors
bull Diet stress smoking drug abuse
ndash Genetics family history a good predictor
bull Infection
bull Inflammation
The answer may lie in complex interactions between multiple components of susceptibility This may make it very difficult to show a direct causal relationship between periodontal disease and systemic conditions
Thank you
KarenFNovakuthtmcedu
References Dasanayake AP1 Chhun N Tanner AC Craig RG Lee MJ Moore AF Norman RG J Dent Res 2008 Periodontal pathogens and gestational diabetes mellitus 2008 Apr87(4)328-33 Xiong X1 Elkind-Hirsch KE Vastardis S Delarosa RL Pridjian G Buekens P Periodontal disease is associated with gestational diabetes mellitus a case-control study J Periodontol 2009 Nov80(11)1742-9 Ruiz DR1 Romito GA Dib SA Periodontal disease in gestational and type 1 diabetes mellitus pregnant women Oral Dis 2011 Jul17(5)515-21 Xiong X Elkind-Hirsch KE Xie Y Delarosa R Maney P Pridjian G Buekens P Periodontal disease as a potential risk factor for the development of diabetes in women with a prior history of gestational diabetes mellitus J Public Health Dent 2013 Winter73(1)41-9 Michalowicz BS Hodges JS DiANgelis AJ Lupo VR Novak MJ Ferguson JE et al Treatment of periodontal disease and the risk of preterm birth N Engl J Med 2006 3551885-94 Offenbacher S Beck JD Jared HL Maaureilllo SM Mendoza LC Couper DJ et al Effects of periodontal therapy on rate or preterm delivery a randomized controlled trial Maternal Oral Therapy to Reduce Obstetric Risk (MOTOR) Investigators Obstet Gynecol 2009 114551-9 Committee on Health Care for Underserved Women Committee Opinion Oral health care during pregnancy and through the lifespan 2013 122417-422
Study Population
bull 306 matched pairs of pregnant women ndash Ages 16-45
ndash No history of type 1 or type 2 diabetes mellitus
ndash Minimum of 20 teeth
bull 153 with GDM 153 controls without GDM ndash Age raceethnicity and gestational age matched
bull Categorized by presenceabsence of periodontal disease (PD)
Data Collection bull Enrollment
ndash Consent and HIPAA authorization
ndash Medical and dental histories
ndash Comprehensive periodontal examination
bull Plaque index probing pocket depths clinical
attachment levels bleeding index calculus index
ndash Periodontitis (PD)
bull At least 4 teeth with PD gt4mm LOA gt2mm and
BOP
Data Collection
Laboratory samples
bull Serum ndash assessed by ELISA and Luminex
bull Subgingival plaque ndash biofilm microbiota assessed by qPCR
Data collection bull Post-delivery maternal and fetal outcomes
ndash Maternal pre-eclampsia premature labor premature rupture of membranes urinary tract infections chorioamnionitisfunisitis induction of labor operative vaginal deliveries or unplanned cesarean
Multivariable logistic regression GEE adjusted for smoking and calculus Variables used for matching were not used as covariates in the GEE matched analysis regression
modeling These included age raceethnicity and gestational age at enrollment
Conclusion bull Women in this study with the combination of GDM
plus periodontal disease had
ndash a 23-fold greater risk for developing adverse maternal outcomes than women with either GDM or periodontal disease alone
Fig 1
Gestational Diabetes Mellitus Periodontal Disease
Negative Maternal and Fetal Outcomes
Combined Effect
Periodontal Variable
Adverse pregnancy outcomes
n=130
No adverse pregnancy outcomes
n=176
P- value (Wilcoxon test)
Plaque index 056 (019) 053 (017) 008
Probing depth 28 (051) 27 (056) 001
Clinical attachment loss
063 (055) 062 (055) 084
Calculus (0-3) 044 (037) 039 (037) 017
Bleeding (0-3) 036 (030) 033 (031) 007
Case Control Comparison
Periodontal Variable
GDM + n=153
GDM ndash n=153
(P- value) (Wilcoxon
test)
Plaque index 055 (017) 053 (019) 026
Probing depth 28 (057) 27 (049) 008
Clinical attachment loss
066 (056) 058 (054) 021
Calculus (0-3) 044 (037) 039 (037) 020
Bleeding (0-3) 037 (031) 032 (030) 021
Case Control Comparison
Conclusions bull Probing pocket depth independent of GDM
status was a significant predictor of adverse pregnancy outcomes (p=001)
bull Bleeding on probing was related to adverse pregnancy outcomes (p=007)
bull GDM status was related to probing pocket depth (p=008)
Odds Ratios for Adverse Fetal Outcomes
Contrasts for PD and GDM status Odds Ratio 95 CI
PD+ GDM+ vs PD- GDM- 142 064 314
PD+ GDM+ vs PD- GDM+ 147 066 327
PD+ GDM+ vs PD+ GDM- 119 058 242
Multivariable logistic regression GEE adjusted for smoking and calculus Variables used for matching were not used as covariates in the GEE matched analysis regression
modeling These included age raceethnicity and gestational age at enrollment
Conclusion bull Women in this study with the combination of GDM
plus periodontal disease had
ndash no greater risk for adverse fetal outcomes than women with either GDM or periodontal disease alone
Conclusions bull Women in this study with the combination of GDM
plus periodontal disease had
ndash a 23-fold greater risk for developing adverse maternal outcomes than women with either GDM or periodontal disease alone bull Probing pocket depth independent of GDM status was a
significant predictor of adverse pregnancy outcomes (p=001)
bull Bleeding on probing was related to adverse pregnancy outcomes (p=007)
bull GDM status was related to probing pocket depth (p=008)
ndash no greater risk for adverse fetal outcomes than women with either GDM or periodontal disease alone
Exploring the possible biology of an oral-systemic link
ldquoOral health is integral to general healthrdquo
A ldquosilent epidemic of oral diseases is affecting our most vulnerable citizensrdquo
How could periodontal disease contribute to systemic
conditions
Defining periodontal disease
bull An inflammatory disease that is initiated by the
accumulation of Gram-negative bacteria around the
teeth and gums
Potential mechanisms
bull Dissemination of periodontal infection
bull Dissemination of periodontal inflammation
Is there evidence that periodontal bacteria play a major role
bull ldquoGuilt by associationrdquo
ndash Periodontal bacteria rarely found in systemic organs
ndash Case of fetal demise due to oral Fusobacterial infection extremely rare
ndash No cases of stroke or myocardial infarction due to periodontal infection
Letrsquos look at inflammation as a potential culprit
Inflammation
bull Initiates the host response to challenge
bull Brings immune cells and molecules to the site of challenge
bull A tightly regulated mechanism
bull When dysregulated leads to pathology
ndash Genetic (polymorphisms in gene structure)
ndash Environmental (smoking stress diet)
ndash Systemic (obesity type 2 diabetes hormonal)
Including
Periodontal disease
Periodontal disease and systemic disease
bull Risk indicator or risk factor
ndash Risk indicator ndash periodontal disease and the systemic condition share common etiologies
ndash Risk factor ndash oral infectioninflammation contributes to the genesis of the systemic condition Remove periodontal disease and the systemic condition improves
What is the evidence
bull Cross sectional studies
ndash periodontal disease may be a risk indicator for systemic inflammatory conditions in certain populations
ndash failed to show a causal effect suggesting that periodontal disease is not a risk factor for systemic disease
What is the answer
bull Periodontitis and systemic inflammatory conditions have complex etiologies
bull Influenced by
ndash Socio-economic status
ndash Lifestyle choicesbehaviors
bull Diet stress smoking drug abuse
ndash Genetics family history a good predictor
bull Infection
bull Inflammation
The answer may lie in complex interactions between multiple components of susceptibility This may make it very difficult to show a direct causal relationship between periodontal disease and systemic conditions
Thank you
KarenFNovakuthtmcedu
References Dasanayake AP1 Chhun N Tanner AC Craig RG Lee MJ Moore AF Norman RG J Dent Res 2008 Periodontal pathogens and gestational diabetes mellitus 2008 Apr87(4)328-33 Xiong X1 Elkind-Hirsch KE Vastardis S Delarosa RL Pridjian G Buekens P Periodontal disease is associated with gestational diabetes mellitus a case-control study J Periodontol 2009 Nov80(11)1742-9 Ruiz DR1 Romito GA Dib SA Periodontal disease in gestational and type 1 diabetes mellitus pregnant women Oral Dis 2011 Jul17(5)515-21 Xiong X Elkind-Hirsch KE Xie Y Delarosa R Maney P Pridjian G Buekens P Periodontal disease as a potential risk factor for the development of diabetes in women with a prior history of gestational diabetes mellitus J Public Health Dent 2013 Winter73(1)41-9 Michalowicz BS Hodges JS DiANgelis AJ Lupo VR Novak MJ Ferguson JE et al Treatment of periodontal disease and the risk of preterm birth N Engl J Med 2006 3551885-94 Offenbacher S Beck JD Jared HL Maaureilllo SM Mendoza LC Couper DJ et al Effects of periodontal therapy on rate or preterm delivery a randomized controlled trial Maternal Oral Therapy to Reduce Obstetric Risk (MOTOR) Investigators Obstet Gynecol 2009 114551-9 Committee on Health Care for Underserved Women Committee Opinion Oral health care during pregnancy and through the lifespan 2013 122417-422
Data Collection bull Enrollment
ndash Consent and HIPAA authorization
ndash Medical and dental histories
ndash Comprehensive periodontal examination
bull Plaque index probing pocket depths clinical
attachment levels bleeding index calculus index
ndash Periodontitis (PD)
bull At least 4 teeth with PD gt4mm LOA gt2mm and
BOP
Data Collection
Laboratory samples
bull Serum ndash assessed by ELISA and Luminex
bull Subgingival plaque ndash biofilm microbiota assessed by qPCR
Data collection bull Post-delivery maternal and fetal outcomes
ndash Maternal pre-eclampsia premature labor premature rupture of membranes urinary tract infections chorioamnionitisfunisitis induction of labor operative vaginal deliveries or unplanned cesarean
Multivariable logistic regression GEE adjusted for smoking and calculus Variables used for matching were not used as covariates in the GEE matched analysis regression
modeling These included age raceethnicity and gestational age at enrollment
Conclusion bull Women in this study with the combination of GDM
plus periodontal disease had
ndash a 23-fold greater risk for developing adverse maternal outcomes than women with either GDM or periodontal disease alone
Fig 1
Gestational Diabetes Mellitus Periodontal Disease
Negative Maternal and Fetal Outcomes
Combined Effect
Periodontal Variable
Adverse pregnancy outcomes
n=130
No adverse pregnancy outcomes
n=176
P- value (Wilcoxon test)
Plaque index 056 (019) 053 (017) 008
Probing depth 28 (051) 27 (056) 001
Clinical attachment loss
063 (055) 062 (055) 084
Calculus (0-3) 044 (037) 039 (037) 017
Bleeding (0-3) 036 (030) 033 (031) 007
Case Control Comparison
Periodontal Variable
GDM + n=153
GDM ndash n=153
(P- value) (Wilcoxon
test)
Plaque index 055 (017) 053 (019) 026
Probing depth 28 (057) 27 (049) 008
Clinical attachment loss
066 (056) 058 (054) 021
Calculus (0-3) 044 (037) 039 (037) 020
Bleeding (0-3) 037 (031) 032 (030) 021
Case Control Comparison
Conclusions bull Probing pocket depth independent of GDM
status was a significant predictor of adverse pregnancy outcomes (p=001)
bull Bleeding on probing was related to adverse pregnancy outcomes (p=007)
bull GDM status was related to probing pocket depth (p=008)
Odds Ratios for Adverse Fetal Outcomes
Contrasts for PD and GDM status Odds Ratio 95 CI
PD+ GDM+ vs PD- GDM- 142 064 314
PD+ GDM+ vs PD- GDM+ 147 066 327
PD+ GDM+ vs PD+ GDM- 119 058 242
Multivariable logistic regression GEE adjusted for smoking and calculus Variables used for matching were not used as covariates in the GEE matched analysis regression
modeling These included age raceethnicity and gestational age at enrollment
Conclusion bull Women in this study with the combination of GDM
plus periodontal disease had
ndash no greater risk for adverse fetal outcomes than women with either GDM or periodontal disease alone
Conclusions bull Women in this study with the combination of GDM
plus periodontal disease had
ndash a 23-fold greater risk for developing adverse maternal outcomes than women with either GDM or periodontal disease alone bull Probing pocket depth independent of GDM status was a
significant predictor of adverse pregnancy outcomes (p=001)
bull Bleeding on probing was related to adverse pregnancy outcomes (p=007)
bull GDM status was related to probing pocket depth (p=008)
ndash no greater risk for adverse fetal outcomes than women with either GDM or periodontal disease alone
Exploring the possible biology of an oral-systemic link
ldquoOral health is integral to general healthrdquo
A ldquosilent epidemic of oral diseases is affecting our most vulnerable citizensrdquo
How could periodontal disease contribute to systemic
conditions
Defining periodontal disease
bull An inflammatory disease that is initiated by the
accumulation of Gram-negative bacteria around the
teeth and gums
Potential mechanisms
bull Dissemination of periodontal infection
bull Dissemination of periodontal inflammation
Is there evidence that periodontal bacteria play a major role
bull ldquoGuilt by associationrdquo
ndash Periodontal bacteria rarely found in systemic organs
ndash Case of fetal demise due to oral Fusobacterial infection extremely rare
ndash No cases of stroke or myocardial infarction due to periodontal infection
Letrsquos look at inflammation as a potential culprit
Inflammation
bull Initiates the host response to challenge
bull Brings immune cells and molecules to the site of challenge
bull A tightly regulated mechanism
bull When dysregulated leads to pathology
ndash Genetic (polymorphisms in gene structure)
ndash Environmental (smoking stress diet)
ndash Systemic (obesity type 2 diabetes hormonal)
Including
Periodontal disease
Periodontal disease and systemic disease
bull Risk indicator or risk factor
ndash Risk indicator ndash periodontal disease and the systemic condition share common etiologies
ndash Risk factor ndash oral infectioninflammation contributes to the genesis of the systemic condition Remove periodontal disease and the systemic condition improves
What is the evidence
bull Cross sectional studies
ndash periodontal disease may be a risk indicator for systemic inflammatory conditions in certain populations
ndash failed to show a causal effect suggesting that periodontal disease is not a risk factor for systemic disease
What is the answer
bull Periodontitis and systemic inflammatory conditions have complex etiologies
bull Influenced by
ndash Socio-economic status
ndash Lifestyle choicesbehaviors
bull Diet stress smoking drug abuse
ndash Genetics family history a good predictor
bull Infection
bull Inflammation
The answer may lie in complex interactions between multiple components of susceptibility This may make it very difficult to show a direct causal relationship between periodontal disease and systemic conditions
Thank you
KarenFNovakuthtmcedu
References Dasanayake AP1 Chhun N Tanner AC Craig RG Lee MJ Moore AF Norman RG J Dent Res 2008 Periodontal pathogens and gestational diabetes mellitus 2008 Apr87(4)328-33 Xiong X1 Elkind-Hirsch KE Vastardis S Delarosa RL Pridjian G Buekens P Periodontal disease is associated with gestational diabetes mellitus a case-control study J Periodontol 2009 Nov80(11)1742-9 Ruiz DR1 Romito GA Dib SA Periodontal disease in gestational and type 1 diabetes mellitus pregnant women Oral Dis 2011 Jul17(5)515-21 Xiong X Elkind-Hirsch KE Xie Y Delarosa R Maney P Pridjian G Buekens P Periodontal disease as a potential risk factor for the development of diabetes in women with a prior history of gestational diabetes mellitus J Public Health Dent 2013 Winter73(1)41-9 Michalowicz BS Hodges JS DiANgelis AJ Lupo VR Novak MJ Ferguson JE et al Treatment of periodontal disease and the risk of preterm birth N Engl J Med 2006 3551885-94 Offenbacher S Beck JD Jared HL Maaureilllo SM Mendoza LC Couper DJ et al Effects of periodontal therapy on rate or preterm delivery a randomized controlled trial Maternal Oral Therapy to Reduce Obstetric Risk (MOTOR) Investigators Obstet Gynecol 2009 114551-9 Committee on Health Care for Underserved Women Committee Opinion Oral health care during pregnancy and through the lifespan 2013 122417-422
Data Collection
Laboratory samples
bull Serum ndash assessed by ELISA and Luminex
bull Subgingival plaque ndash biofilm microbiota assessed by qPCR
Data collection bull Post-delivery maternal and fetal outcomes
ndash Maternal pre-eclampsia premature labor premature rupture of membranes urinary tract infections chorioamnionitisfunisitis induction of labor operative vaginal deliveries or unplanned cesarean
Multivariable logistic regression GEE adjusted for smoking and calculus Variables used for matching were not used as covariates in the GEE matched analysis regression
modeling These included age raceethnicity and gestational age at enrollment
Conclusion bull Women in this study with the combination of GDM
plus periodontal disease had
ndash a 23-fold greater risk for developing adverse maternal outcomes than women with either GDM or periodontal disease alone
Fig 1
Gestational Diabetes Mellitus Periodontal Disease
Negative Maternal and Fetal Outcomes
Combined Effect
Periodontal Variable
Adverse pregnancy outcomes
n=130
No adverse pregnancy outcomes
n=176
P- value (Wilcoxon test)
Plaque index 056 (019) 053 (017) 008
Probing depth 28 (051) 27 (056) 001
Clinical attachment loss
063 (055) 062 (055) 084
Calculus (0-3) 044 (037) 039 (037) 017
Bleeding (0-3) 036 (030) 033 (031) 007
Case Control Comparison
Periodontal Variable
GDM + n=153
GDM ndash n=153
(P- value) (Wilcoxon
test)
Plaque index 055 (017) 053 (019) 026
Probing depth 28 (057) 27 (049) 008
Clinical attachment loss
066 (056) 058 (054) 021
Calculus (0-3) 044 (037) 039 (037) 020
Bleeding (0-3) 037 (031) 032 (030) 021
Case Control Comparison
Conclusions bull Probing pocket depth independent of GDM
status was a significant predictor of adverse pregnancy outcomes (p=001)
bull Bleeding on probing was related to adverse pregnancy outcomes (p=007)
bull GDM status was related to probing pocket depth (p=008)
Odds Ratios for Adverse Fetal Outcomes
Contrasts for PD and GDM status Odds Ratio 95 CI
PD+ GDM+ vs PD- GDM- 142 064 314
PD+ GDM+ vs PD- GDM+ 147 066 327
PD+ GDM+ vs PD+ GDM- 119 058 242
Multivariable logistic regression GEE adjusted for smoking and calculus Variables used for matching were not used as covariates in the GEE matched analysis regression
modeling These included age raceethnicity and gestational age at enrollment
Conclusion bull Women in this study with the combination of GDM
plus periodontal disease had
ndash no greater risk for adverse fetal outcomes than women with either GDM or periodontal disease alone
Conclusions bull Women in this study with the combination of GDM
plus periodontal disease had
ndash a 23-fold greater risk for developing adverse maternal outcomes than women with either GDM or periodontal disease alone bull Probing pocket depth independent of GDM status was a
significant predictor of adverse pregnancy outcomes (p=001)
bull Bleeding on probing was related to adverse pregnancy outcomes (p=007)
bull GDM status was related to probing pocket depth (p=008)
ndash no greater risk for adverse fetal outcomes than women with either GDM or periodontal disease alone
Exploring the possible biology of an oral-systemic link
ldquoOral health is integral to general healthrdquo
A ldquosilent epidemic of oral diseases is affecting our most vulnerable citizensrdquo
How could periodontal disease contribute to systemic
conditions
Defining periodontal disease
bull An inflammatory disease that is initiated by the
accumulation of Gram-negative bacteria around the
teeth and gums
Potential mechanisms
bull Dissemination of periodontal infection
bull Dissemination of periodontal inflammation
Is there evidence that periodontal bacteria play a major role
bull ldquoGuilt by associationrdquo
ndash Periodontal bacteria rarely found in systemic organs
ndash Case of fetal demise due to oral Fusobacterial infection extremely rare
ndash No cases of stroke or myocardial infarction due to periodontal infection
Letrsquos look at inflammation as a potential culprit
Inflammation
bull Initiates the host response to challenge
bull Brings immune cells and molecules to the site of challenge
bull A tightly regulated mechanism
bull When dysregulated leads to pathology
ndash Genetic (polymorphisms in gene structure)
ndash Environmental (smoking stress diet)
ndash Systemic (obesity type 2 diabetes hormonal)
Including
Periodontal disease
Periodontal disease and systemic disease
bull Risk indicator or risk factor
ndash Risk indicator ndash periodontal disease and the systemic condition share common etiologies
ndash Risk factor ndash oral infectioninflammation contributes to the genesis of the systemic condition Remove periodontal disease and the systemic condition improves
What is the evidence
bull Cross sectional studies
ndash periodontal disease may be a risk indicator for systemic inflammatory conditions in certain populations
ndash failed to show a causal effect suggesting that periodontal disease is not a risk factor for systemic disease
What is the answer
bull Periodontitis and systemic inflammatory conditions have complex etiologies
bull Influenced by
ndash Socio-economic status
ndash Lifestyle choicesbehaviors
bull Diet stress smoking drug abuse
ndash Genetics family history a good predictor
bull Infection
bull Inflammation
The answer may lie in complex interactions between multiple components of susceptibility This may make it very difficult to show a direct causal relationship between periodontal disease and systemic conditions
Thank you
KarenFNovakuthtmcedu
References Dasanayake AP1 Chhun N Tanner AC Craig RG Lee MJ Moore AF Norman RG J Dent Res 2008 Periodontal pathogens and gestational diabetes mellitus 2008 Apr87(4)328-33 Xiong X1 Elkind-Hirsch KE Vastardis S Delarosa RL Pridjian G Buekens P Periodontal disease is associated with gestational diabetes mellitus a case-control study J Periodontol 2009 Nov80(11)1742-9 Ruiz DR1 Romito GA Dib SA Periodontal disease in gestational and type 1 diabetes mellitus pregnant women Oral Dis 2011 Jul17(5)515-21 Xiong X Elkind-Hirsch KE Xie Y Delarosa R Maney P Pridjian G Buekens P Periodontal disease as a potential risk factor for the development of diabetes in women with a prior history of gestational diabetes mellitus J Public Health Dent 2013 Winter73(1)41-9 Michalowicz BS Hodges JS DiANgelis AJ Lupo VR Novak MJ Ferguson JE et al Treatment of periodontal disease and the risk of preterm birth N Engl J Med 2006 3551885-94 Offenbacher S Beck JD Jared HL Maaureilllo SM Mendoza LC Couper DJ et al Effects of periodontal therapy on rate or preterm delivery a randomized controlled trial Maternal Oral Therapy to Reduce Obstetric Risk (MOTOR) Investigators Obstet Gynecol 2009 114551-9 Committee on Health Care for Underserved Women Committee Opinion Oral health care during pregnancy and through the lifespan 2013 122417-422
Data collection bull Post-delivery maternal and fetal outcomes
ndash Maternal pre-eclampsia premature labor premature rupture of membranes urinary tract infections chorioamnionitisfunisitis induction of labor operative vaginal deliveries or unplanned cesarean
Multivariable logistic regression GEE adjusted for smoking and calculus Variables used for matching were not used as covariates in the GEE matched analysis regression
modeling These included age raceethnicity and gestational age at enrollment
Conclusion bull Women in this study with the combination of GDM
plus periodontal disease had
ndash a 23-fold greater risk for developing adverse maternal outcomes than women with either GDM or periodontal disease alone
Fig 1
Gestational Diabetes Mellitus Periodontal Disease
Negative Maternal and Fetal Outcomes
Combined Effect
Periodontal Variable
Adverse pregnancy outcomes
n=130
No adverse pregnancy outcomes
n=176
P- value (Wilcoxon test)
Plaque index 056 (019) 053 (017) 008
Probing depth 28 (051) 27 (056) 001
Clinical attachment loss
063 (055) 062 (055) 084
Calculus (0-3) 044 (037) 039 (037) 017
Bleeding (0-3) 036 (030) 033 (031) 007
Case Control Comparison
Periodontal Variable
GDM + n=153
GDM ndash n=153
(P- value) (Wilcoxon
test)
Plaque index 055 (017) 053 (019) 026
Probing depth 28 (057) 27 (049) 008
Clinical attachment loss
066 (056) 058 (054) 021
Calculus (0-3) 044 (037) 039 (037) 020
Bleeding (0-3) 037 (031) 032 (030) 021
Case Control Comparison
Conclusions bull Probing pocket depth independent of GDM
status was a significant predictor of adverse pregnancy outcomes (p=001)
bull Bleeding on probing was related to adverse pregnancy outcomes (p=007)
bull GDM status was related to probing pocket depth (p=008)
Odds Ratios for Adverse Fetal Outcomes
Contrasts for PD and GDM status Odds Ratio 95 CI
PD+ GDM+ vs PD- GDM- 142 064 314
PD+ GDM+ vs PD- GDM+ 147 066 327
PD+ GDM+ vs PD+ GDM- 119 058 242
Multivariable logistic regression GEE adjusted for smoking and calculus Variables used for matching were not used as covariates in the GEE matched analysis regression
modeling These included age raceethnicity and gestational age at enrollment
Conclusion bull Women in this study with the combination of GDM
plus periodontal disease had
ndash no greater risk for adverse fetal outcomes than women with either GDM or periodontal disease alone
Conclusions bull Women in this study with the combination of GDM
plus periodontal disease had
ndash a 23-fold greater risk for developing adverse maternal outcomes than women with either GDM or periodontal disease alone bull Probing pocket depth independent of GDM status was a
significant predictor of adverse pregnancy outcomes (p=001)
bull Bleeding on probing was related to adverse pregnancy outcomes (p=007)
bull GDM status was related to probing pocket depth (p=008)
ndash no greater risk for adverse fetal outcomes than women with either GDM or periodontal disease alone
Exploring the possible biology of an oral-systemic link
ldquoOral health is integral to general healthrdquo
A ldquosilent epidemic of oral diseases is affecting our most vulnerable citizensrdquo
How could periodontal disease contribute to systemic
conditions
Defining periodontal disease
bull An inflammatory disease that is initiated by the
accumulation of Gram-negative bacteria around the
teeth and gums
Potential mechanisms
bull Dissemination of periodontal infection
bull Dissemination of periodontal inflammation
Is there evidence that periodontal bacteria play a major role
bull ldquoGuilt by associationrdquo
ndash Periodontal bacteria rarely found in systemic organs
ndash Case of fetal demise due to oral Fusobacterial infection extremely rare
ndash No cases of stroke or myocardial infarction due to periodontal infection
Letrsquos look at inflammation as a potential culprit
Inflammation
bull Initiates the host response to challenge
bull Brings immune cells and molecules to the site of challenge
bull A tightly regulated mechanism
bull When dysregulated leads to pathology
ndash Genetic (polymorphisms in gene structure)
ndash Environmental (smoking stress diet)
ndash Systemic (obesity type 2 diabetes hormonal)
Including
Periodontal disease
Periodontal disease and systemic disease
bull Risk indicator or risk factor
ndash Risk indicator ndash periodontal disease and the systemic condition share common etiologies
ndash Risk factor ndash oral infectioninflammation contributes to the genesis of the systemic condition Remove periodontal disease and the systemic condition improves
What is the evidence
bull Cross sectional studies
ndash periodontal disease may be a risk indicator for systemic inflammatory conditions in certain populations
ndash failed to show a causal effect suggesting that periodontal disease is not a risk factor for systemic disease
What is the answer
bull Periodontitis and systemic inflammatory conditions have complex etiologies
bull Influenced by
ndash Socio-economic status
ndash Lifestyle choicesbehaviors
bull Diet stress smoking drug abuse
ndash Genetics family history a good predictor
bull Infection
bull Inflammation
The answer may lie in complex interactions between multiple components of susceptibility This may make it very difficult to show a direct causal relationship between periodontal disease and systemic conditions
Thank you
KarenFNovakuthtmcedu
References Dasanayake AP1 Chhun N Tanner AC Craig RG Lee MJ Moore AF Norman RG J Dent Res 2008 Periodontal pathogens and gestational diabetes mellitus 2008 Apr87(4)328-33 Xiong X1 Elkind-Hirsch KE Vastardis S Delarosa RL Pridjian G Buekens P Periodontal disease is associated with gestational diabetes mellitus a case-control study J Periodontol 2009 Nov80(11)1742-9 Ruiz DR1 Romito GA Dib SA Periodontal disease in gestational and type 1 diabetes mellitus pregnant women Oral Dis 2011 Jul17(5)515-21 Xiong X Elkind-Hirsch KE Xie Y Delarosa R Maney P Pridjian G Buekens P Periodontal disease as a potential risk factor for the development of diabetes in women with a prior history of gestational diabetes mellitus J Public Health Dent 2013 Winter73(1)41-9 Michalowicz BS Hodges JS DiANgelis AJ Lupo VR Novak MJ Ferguson JE et al Treatment of periodontal disease and the risk of preterm birth N Engl J Med 2006 3551885-94 Offenbacher S Beck JD Jared HL Maaureilllo SM Mendoza LC Couper DJ et al Effects of periodontal therapy on rate or preterm delivery a randomized controlled trial Maternal Oral Therapy to Reduce Obstetric Risk (MOTOR) Investigators Obstet Gynecol 2009 114551-9 Committee on Health Care for Underserved Women Committee Opinion Oral health care during pregnancy and through the lifespan 2013 122417-422
Multivariable logistic regression GEE adjusted for smoking and calculus Variables used for matching were not used as covariates in the GEE matched analysis regression
modeling These included age raceethnicity and gestational age at enrollment
Conclusion bull Women in this study with the combination of GDM
plus periodontal disease had
ndash a 23-fold greater risk for developing adverse maternal outcomes than women with either GDM or periodontal disease alone
Fig 1
Gestational Diabetes Mellitus Periodontal Disease
Negative Maternal and Fetal Outcomes
Combined Effect
Periodontal Variable
Adverse pregnancy outcomes
n=130
No adverse pregnancy outcomes
n=176
P- value (Wilcoxon test)
Plaque index 056 (019) 053 (017) 008
Probing depth 28 (051) 27 (056) 001
Clinical attachment loss
063 (055) 062 (055) 084
Calculus (0-3) 044 (037) 039 (037) 017
Bleeding (0-3) 036 (030) 033 (031) 007
Case Control Comparison
Periodontal Variable
GDM + n=153
GDM ndash n=153
(P- value) (Wilcoxon
test)
Plaque index 055 (017) 053 (019) 026
Probing depth 28 (057) 27 (049) 008
Clinical attachment loss
066 (056) 058 (054) 021
Calculus (0-3) 044 (037) 039 (037) 020
Bleeding (0-3) 037 (031) 032 (030) 021
Case Control Comparison
Conclusions bull Probing pocket depth independent of GDM
status was a significant predictor of adverse pregnancy outcomes (p=001)
bull Bleeding on probing was related to adverse pregnancy outcomes (p=007)
bull GDM status was related to probing pocket depth (p=008)
Odds Ratios for Adverse Fetal Outcomes
Contrasts for PD and GDM status Odds Ratio 95 CI
PD+ GDM+ vs PD- GDM- 142 064 314
PD+ GDM+ vs PD- GDM+ 147 066 327
PD+ GDM+ vs PD+ GDM- 119 058 242
Multivariable logistic regression GEE adjusted for smoking and calculus Variables used for matching were not used as covariates in the GEE matched analysis regression
modeling These included age raceethnicity and gestational age at enrollment
Conclusion bull Women in this study with the combination of GDM
plus periodontal disease had
ndash no greater risk for adverse fetal outcomes than women with either GDM or periodontal disease alone
Conclusions bull Women in this study with the combination of GDM
plus periodontal disease had
ndash a 23-fold greater risk for developing adverse maternal outcomes than women with either GDM or periodontal disease alone bull Probing pocket depth independent of GDM status was a
significant predictor of adverse pregnancy outcomes (p=001)
bull Bleeding on probing was related to adverse pregnancy outcomes (p=007)
bull GDM status was related to probing pocket depth (p=008)
ndash no greater risk for adverse fetal outcomes than women with either GDM or periodontal disease alone
Exploring the possible biology of an oral-systemic link
ldquoOral health is integral to general healthrdquo
A ldquosilent epidemic of oral diseases is affecting our most vulnerable citizensrdquo
How could periodontal disease contribute to systemic
conditions
Defining periodontal disease
bull An inflammatory disease that is initiated by the
accumulation of Gram-negative bacteria around the
teeth and gums
Potential mechanisms
bull Dissemination of periodontal infection
bull Dissemination of periodontal inflammation
Is there evidence that periodontal bacteria play a major role
bull ldquoGuilt by associationrdquo
ndash Periodontal bacteria rarely found in systemic organs
ndash Case of fetal demise due to oral Fusobacterial infection extremely rare
ndash No cases of stroke or myocardial infarction due to periodontal infection
Letrsquos look at inflammation as a potential culprit
Inflammation
bull Initiates the host response to challenge
bull Brings immune cells and molecules to the site of challenge
bull A tightly regulated mechanism
bull When dysregulated leads to pathology
ndash Genetic (polymorphisms in gene structure)
ndash Environmental (smoking stress diet)
ndash Systemic (obesity type 2 diabetes hormonal)
Including
Periodontal disease
Periodontal disease and systemic disease
bull Risk indicator or risk factor
ndash Risk indicator ndash periodontal disease and the systemic condition share common etiologies
ndash Risk factor ndash oral infectioninflammation contributes to the genesis of the systemic condition Remove periodontal disease and the systemic condition improves
What is the evidence
bull Cross sectional studies
ndash periodontal disease may be a risk indicator for systemic inflammatory conditions in certain populations
ndash failed to show a causal effect suggesting that periodontal disease is not a risk factor for systemic disease
What is the answer
bull Periodontitis and systemic inflammatory conditions have complex etiologies
bull Influenced by
ndash Socio-economic status
ndash Lifestyle choicesbehaviors
bull Diet stress smoking drug abuse
ndash Genetics family history a good predictor
bull Infection
bull Inflammation
The answer may lie in complex interactions between multiple components of susceptibility This may make it very difficult to show a direct causal relationship between periodontal disease and systemic conditions
Thank you
KarenFNovakuthtmcedu
References Dasanayake AP1 Chhun N Tanner AC Craig RG Lee MJ Moore AF Norman RG J Dent Res 2008 Periodontal pathogens and gestational diabetes mellitus 2008 Apr87(4)328-33 Xiong X1 Elkind-Hirsch KE Vastardis S Delarosa RL Pridjian G Buekens P Periodontal disease is associated with gestational diabetes mellitus a case-control study J Periodontol 2009 Nov80(11)1742-9 Ruiz DR1 Romito GA Dib SA Periodontal disease in gestational and type 1 diabetes mellitus pregnant women Oral Dis 2011 Jul17(5)515-21 Xiong X Elkind-Hirsch KE Xie Y Delarosa R Maney P Pridjian G Buekens P Periodontal disease as a potential risk factor for the development of diabetes in women with a prior history of gestational diabetes mellitus J Public Health Dent 2013 Winter73(1)41-9 Michalowicz BS Hodges JS DiANgelis AJ Lupo VR Novak MJ Ferguson JE et al Treatment of periodontal disease and the risk of preterm birth N Engl J Med 2006 3551885-94 Offenbacher S Beck JD Jared HL Maaureilllo SM Mendoza LC Couper DJ et al Effects of periodontal therapy on rate or preterm delivery a randomized controlled trial Maternal Oral Therapy to Reduce Obstetric Risk (MOTOR) Investigators Obstet Gynecol 2009 114551-9 Committee on Health Care for Underserved Women Committee Opinion Oral health care during pregnancy and through the lifespan 2013 122417-422
Multivariable logistic regression GEE adjusted for smoking and calculus Variables used for matching were not used as covariates in the GEE matched analysis regression
modeling These included age raceethnicity and gestational age at enrollment
Conclusion bull Women in this study with the combination of GDM
plus periodontal disease had
ndash a 23-fold greater risk for developing adverse maternal outcomes than women with either GDM or periodontal disease alone
Fig 1
Gestational Diabetes Mellitus Periodontal Disease
Negative Maternal and Fetal Outcomes
Combined Effect
Periodontal Variable
Adverse pregnancy outcomes
n=130
No adverse pregnancy outcomes
n=176
P- value (Wilcoxon test)
Plaque index 056 (019) 053 (017) 008
Probing depth 28 (051) 27 (056) 001
Clinical attachment loss
063 (055) 062 (055) 084
Calculus (0-3) 044 (037) 039 (037) 017
Bleeding (0-3) 036 (030) 033 (031) 007
Case Control Comparison
Periodontal Variable
GDM + n=153
GDM ndash n=153
(P- value) (Wilcoxon
test)
Plaque index 055 (017) 053 (019) 026
Probing depth 28 (057) 27 (049) 008
Clinical attachment loss
066 (056) 058 (054) 021
Calculus (0-3) 044 (037) 039 (037) 020
Bleeding (0-3) 037 (031) 032 (030) 021
Case Control Comparison
Conclusions bull Probing pocket depth independent of GDM
status was a significant predictor of adverse pregnancy outcomes (p=001)
bull Bleeding on probing was related to adverse pregnancy outcomes (p=007)
bull GDM status was related to probing pocket depth (p=008)
Odds Ratios for Adverse Fetal Outcomes
Contrasts for PD and GDM status Odds Ratio 95 CI
PD+ GDM+ vs PD- GDM- 142 064 314
PD+ GDM+ vs PD- GDM+ 147 066 327
PD+ GDM+ vs PD+ GDM- 119 058 242
Multivariable logistic regression GEE adjusted for smoking and calculus Variables used for matching were not used as covariates in the GEE matched analysis regression
modeling These included age raceethnicity and gestational age at enrollment
Conclusion bull Women in this study with the combination of GDM
plus periodontal disease had
ndash no greater risk for adverse fetal outcomes than women with either GDM or periodontal disease alone
Conclusions bull Women in this study with the combination of GDM
plus periodontal disease had
ndash a 23-fold greater risk for developing adverse maternal outcomes than women with either GDM or periodontal disease alone bull Probing pocket depth independent of GDM status was a
significant predictor of adverse pregnancy outcomes (p=001)
bull Bleeding on probing was related to adverse pregnancy outcomes (p=007)
bull GDM status was related to probing pocket depth (p=008)
ndash no greater risk for adverse fetal outcomes than women with either GDM or periodontal disease alone
Exploring the possible biology of an oral-systemic link
ldquoOral health is integral to general healthrdquo
A ldquosilent epidemic of oral diseases is affecting our most vulnerable citizensrdquo
How could periodontal disease contribute to systemic
conditions
Defining periodontal disease
bull An inflammatory disease that is initiated by the
accumulation of Gram-negative bacteria around the
teeth and gums
Potential mechanisms
bull Dissemination of periodontal infection
bull Dissemination of periodontal inflammation
Is there evidence that periodontal bacteria play a major role
bull ldquoGuilt by associationrdquo
ndash Periodontal bacteria rarely found in systemic organs
ndash Case of fetal demise due to oral Fusobacterial infection extremely rare
ndash No cases of stroke or myocardial infarction due to periodontal infection
Letrsquos look at inflammation as a potential culprit
Inflammation
bull Initiates the host response to challenge
bull Brings immune cells and molecules to the site of challenge
bull A tightly regulated mechanism
bull When dysregulated leads to pathology
ndash Genetic (polymorphisms in gene structure)
ndash Environmental (smoking stress diet)
ndash Systemic (obesity type 2 diabetes hormonal)
Including
Periodontal disease
Periodontal disease and systemic disease
bull Risk indicator or risk factor
ndash Risk indicator ndash periodontal disease and the systemic condition share common etiologies
ndash Risk factor ndash oral infectioninflammation contributes to the genesis of the systemic condition Remove periodontal disease and the systemic condition improves
What is the evidence
bull Cross sectional studies
ndash periodontal disease may be a risk indicator for systemic inflammatory conditions in certain populations
ndash failed to show a causal effect suggesting that periodontal disease is not a risk factor for systemic disease
What is the answer
bull Periodontitis and systemic inflammatory conditions have complex etiologies
bull Influenced by
ndash Socio-economic status
ndash Lifestyle choicesbehaviors
bull Diet stress smoking drug abuse
ndash Genetics family history a good predictor
bull Infection
bull Inflammation
The answer may lie in complex interactions between multiple components of susceptibility This may make it very difficult to show a direct causal relationship between periodontal disease and systemic conditions
Thank you
KarenFNovakuthtmcedu
References Dasanayake AP1 Chhun N Tanner AC Craig RG Lee MJ Moore AF Norman RG J Dent Res 2008 Periodontal pathogens and gestational diabetes mellitus 2008 Apr87(4)328-33 Xiong X1 Elkind-Hirsch KE Vastardis S Delarosa RL Pridjian G Buekens P Periodontal disease is associated with gestational diabetes mellitus a case-control study J Periodontol 2009 Nov80(11)1742-9 Ruiz DR1 Romito GA Dib SA Periodontal disease in gestational and type 1 diabetes mellitus pregnant women Oral Dis 2011 Jul17(5)515-21 Xiong X Elkind-Hirsch KE Xie Y Delarosa R Maney P Pridjian G Buekens P Periodontal disease as a potential risk factor for the development of diabetes in women with a prior history of gestational diabetes mellitus J Public Health Dent 2013 Winter73(1)41-9 Michalowicz BS Hodges JS DiANgelis AJ Lupo VR Novak MJ Ferguson JE et al Treatment of periodontal disease and the risk of preterm birth N Engl J Med 2006 3551885-94 Offenbacher S Beck JD Jared HL Maaureilllo SM Mendoza LC Couper DJ et al Effects of periodontal therapy on rate or preterm delivery a randomized controlled trial Maternal Oral Therapy to Reduce Obstetric Risk (MOTOR) Investigators Obstet Gynecol 2009 114551-9 Committee on Health Care for Underserved Women Committee Opinion Oral health care during pregnancy and through the lifespan 2013 122417-422
Multivariable logistic regression GEE adjusted for smoking and calculus Variables used for matching were not used as covariates in the GEE matched analysis regression
modeling These included age raceethnicity and gestational age at enrollment
Conclusion bull Women in this study with the combination of GDM
plus periodontal disease had
ndash a 23-fold greater risk for developing adverse maternal outcomes than women with either GDM or periodontal disease alone
Fig 1
Gestational Diabetes Mellitus Periodontal Disease
Negative Maternal and Fetal Outcomes
Combined Effect
Periodontal Variable
Adverse pregnancy outcomes
n=130
No adverse pregnancy outcomes
n=176
P- value (Wilcoxon test)
Plaque index 056 (019) 053 (017) 008
Probing depth 28 (051) 27 (056) 001
Clinical attachment loss
063 (055) 062 (055) 084
Calculus (0-3) 044 (037) 039 (037) 017
Bleeding (0-3) 036 (030) 033 (031) 007
Case Control Comparison
Periodontal Variable
GDM + n=153
GDM ndash n=153
(P- value) (Wilcoxon
test)
Plaque index 055 (017) 053 (019) 026
Probing depth 28 (057) 27 (049) 008
Clinical attachment loss
066 (056) 058 (054) 021
Calculus (0-3) 044 (037) 039 (037) 020
Bleeding (0-3) 037 (031) 032 (030) 021
Case Control Comparison
Conclusions bull Probing pocket depth independent of GDM
status was a significant predictor of adverse pregnancy outcomes (p=001)
bull Bleeding on probing was related to adverse pregnancy outcomes (p=007)
bull GDM status was related to probing pocket depth (p=008)
Odds Ratios for Adverse Fetal Outcomes
Contrasts for PD and GDM status Odds Ratio 95 CI
PD+ GDM+ vs PD- GDM- 142 064 314
PD+ GDM+ vs PD- GDM+ 147 066 327
PD+ GDM+ vs PD+ GDM- 119 058 242
Multivariable logistic regression GEE adjusted for smoking and calculus Variables used for matching were not used as covariates in the GEE matched analysis regression
modeling These included age raceethnicity and gestational age at enrollment
Conclusion bull Women in this study with the combination of GDM
plus periodontal disease had
ndash no greater risk for adverse fetal outcomes than women with either GDM or periodontal disease alone
Conclusions bull Women in this study with the combination of GDM
plus periodontal disease had
ndash a 23-fold greater risk for developing adverse maternal outcomes than women with either GDM or periodontal disease alone bull Probing pocket depth independent of GDM status was a
significant predictor of adverse pregnancy outcomes (p=001)
bull Bleeding on probing was related to adverse pregnancy outcomes (p=007)
bull GDM status was related to probing pocket depth (p=008)
ndash no greater risk for adverse fetal outcomes than women with either GDM or periodontal disease alone
Exploring the possible biology of an oral-systemic link
ldquoOral health is integral to general healthrdquo
A ldquosilent epidemic of oral diseases is affecting our most vulnerable citizensrdquo
How could periodontal disease contribute to systemic
conditions
Defining periodontal disease
bull An inflammatory disease that is initiated by the
accumulation of Gram-negative bacteria around the
teeth and gums
Potential mechanisms
bull Dissemination of periodontal infection
bull Dissemination of periodontal inflammation
Is there evidence that periodontal bacteria play a major role
bull ldquoGuilt by associationrdquo
ndash Periodontal bacteria rarely found in systemic organs
ndash Case of fetal demise due to oral Fusobacterial infection extremely rare
ndash No cases of stroke or myocardial infarction due to periodontal infection
Letrsquos look at inflammation as a potential culprit
Inflammation
bull Initiates the host response to challenge
bull Brings immune cells and molecules to the site of challenge
bull A tightly regulated mechanism
bull When dysregulated leads to pathology
ndash Genetic (polymorphisms in gene structure)
ndash Environmental (smoking stress diet)
ndash Systemic (obesity type 2 diabetes hormonal)
Including
Periodontal disease
Periodontal disease and systemic disease
bull Risk indicator or risk factor
ndash Risk indicator ndash periodontal disease and the systemic condition share common etiologies
ndash Risk factor ndash oral infectioninflammation contributes to the genesis of the systemic condition Remove periodontal disease and the systemic condition improves
What is the evidence
bull Cross sectional studies
ndash periodontal disease may be a risk indicator for systemic inflammatory conditions in certain populations
ndash failed to show a causal effect suggesting that periodontal disease is not a risk factor for systemic disease
What is the answer
bull Periodontitis and systemic inflammatory conditions have complex etiologies
bull Influenced by
ndash Socio-economic status
ndash Lifestyle choicesbehaviors
bull Diet stress smoking drug abuse
ndash Genetics family history a good predictor
bull Infection
bull Inflammation
The answer may lie in complex interactions between multiple components of susceptibility This may make it very difficult to show a direct causal relationship between periodontal disease and systemic conditions
Thank you
KarenFNovakuthtmcedu
References Dasanayake AP1 Chhun N Tanner AC Craig RG Lee MJ Moore AF Norman RG J Dent Res 2008 Periodontal pathogens and gestational diabetes mellitus 2008 Apr87(4)328-33 Xiong X1 Elkind-Hirsch KE Vastardis S Delarosa RL Pridjian G Buekens P Periodontal disease is associated with gestational diabetes mellitus a case-control study J Periodontol 2009 Nov80(11)1742-9 Ruiz DR1 Romito GA Dib SA Periodontal disease in gestational and type 1 diabetes mellitus pregnant women Oral Dis 2011 Jul17(5)515-21 Xiong X Elkind-Hirsch KE Xie Y Delarosa R Maney P Pridjian G Buekens P Periodontal disease as a potential risk factor for the development of diabetes in women with a prior history of gestational diabetes mellitus J Public Health Dent 2013 Winter73(1)41-9 Michalowicz BS Hodges JS DiANgelis AJ Lupo VR Novak MJ Ferguson JE et al Treatment of periodontal disease and the risk of preterm birth N Engl J Med 2006 3551885-94 Offenbacher S Beck JD Jared HL Maaureilllo SM Mendoza LC Couper DJ et al Effects of periodontal therapy on rate or preterm delivery a randomized controlled trial Maternal Oral Therapy to Reduce Obstetric Risk (MOTOR) Investigators Obstet Gynecol 2009 114551-9 Committee on Health Care for Underserved Women Committee Opinion Oral health care during pregnancy and through the lifespan 2013 122417-422
Odds Ratios for Adverse Maternal Outcomes
Contrasts for PD and GDM status Odds Ratio 95 CI
PD+ GDM+ vs PD- GDM- 23 106 48
PD+ GDM+ vs PD- GDM+ 197 088 44
PD+ GDM+ vs PD+ GDM- 177 085 37
Multivariable logistic regression GEE adjusted for smoking and calculus Variables used for matching were not used as covariates in the GEE matched analysis regression
modeling These included age raceethnicity and gestational age at enrollment
Conclusion bull Women in this study with the combination of GDM
plus periodontal disease had
ndash a 23-fold greater risk for developing adverse maternal outcomes than women with either GDM or periodontal disease alone
Fig 1
Gestational Diabetes Mellitus Periodontal Disease
Negative Maternal and Fetal Outcomes
Combined Effect
Periodontal Variable
Adverse pregnancy outcomes
n=130
No adverse pregnancy outcomes
n=176
P- value (Wilcoxon test)
Plaque index 056 (019) 053 (017) 008
Probing depth 28 (051) 27 (056) 001
Clinical attachment loss
063 (055) 062 (055) 084
Calculus (0-3) 044 (037) 039 (037) 017
Bleeding (0-3) 036 (030) 033 (031) 007
Case Control Comparison
Periodontal Variable
GDM + n=153
GDM ndash n=153
(P- value) (Wilcoxon
test)
Plaque index 055 (017) 053 (019) 026
Probing depth 28 (057) 27 (049) 008
Clinical attachment loss
066 (056) 058 (054) 021
Calculus (0-3) 044 (037) 039 (037) 020
Bleeding (0-3) 037 (031) 032 (030) 021
Case Control Comparison
Conclusions bull Probing pocket depth independent of GDM
status was a significant predictor of adverse pregnancy outcomes (p=001)
bull Bleeding on probing was related to adverse pregnancy outcomes (p=007)
bull GDM status was related to probing pocket depth (p=008)
Odds Ratios for Adverse Fetal Outcomes
Contrasts for PD and GDM status Odds Ratio 95 CI
PD+ GDM+ vs PD- GDM- 142 064 314
PD+ GDM+ vs PD- GDM+ 147 066 327
PD+ GDM+ vs PD+ GDM- 119 058 242
Multivariable logistic regression GEE adjusted for smoking and calculus Variables used for matching were not used as covariates in the GEE matched analysis regression
modeling These included age raceethnicity and gestational age at enrollment
Conclusion bull Women in this study with the combination of GDM
plus periodontal disease had
ndash no greater risk for adverse fetal outcomes than women with either GDM or periodontal disease alone
Conclusions bull Women in this study with the combination of GDM
plus periodontal disease had
ndash a 23-fold greater risk for developing adverse maternal outcomes than women with either GDM or periodontal disease alone bull Probing pocket depth independent of GDM status was a
significant predictor of adverse pregnancy outcomes (p=001)
bull Bleeding on probing was related to adverse pregnancy outcomes (p=007)
bull GDM status was related to probing pocket depth (p=008)
ndash no greater risk for adverse fetal outcomes than women with either GDM or periodontal disease alone
Exploring the possible biology of an oral-systemic link
ldquoOral health is integral to general healthrdquo
A ldquosilent epidemic of oral diseases is affecting our most vulnerable citizensrdquo
How could periodontal disease contribute to systemic
conditions
Defining periodontal disease
bull An inflammatory disease that is initiated by the
accumulation of Gram-negative bacteria around the
teeth and gums
Potential mechanisms
bull Dissemination of periodontal infection
bull Dissemination of periodontal inflammation
Is there evidence that periodontal bacteria play a major role
bull ldquoGuilt by associationrdquo
ndash Periodontal bacteria rarely found in systemic organs
ndash Case of fetal demise due to oral Fusobacterial infection extremely rare
ndash No cases of stroke or myocardial infarction due to periodontal infection
Letrsquos look at inflammation as a potential culprit
Inflammation
bull Initiates the host response to challenge
bull Brings immune cells and molecules to the site of challenge
bull A tightly regulated mechanism
bull When dysregulated leads to pathology
ndash Genetic (polymorphisms in gene structure)
ndash Environmental (smoking stress diet)
ndash Systemic (obesity type 2 diabetes hormonal)
Including
Periodontal disease
Periodontal disease and systemic disease
bull Risk indicator or risk factor
ndash Risk indicator ndash periodontal disease and the systemic condition share common etiologies
ndash Risk factor ndash oral infectioninflammation contributes to the genesis of the systemic condition Remove periodontal disease and the systemic condition improves
What is the evidence
bull Cross sectional studies
ndash periodontal disease may be a risk indicator for systemic inflammatory conditions in certain populations
ndash failed to show a causal effect suggesting that periodontal disease is not a risk factor for systemic disease
What is the answer
bull Periodontitis and systemic inflammatory conditions have complex etiologies
bull Influenced by
ndash Socio-economic status
ndash Lifestyle choicesbehaviors
bull Diet stress smoking drug abuse
ndash Genetics family history a good predictor
bull Infection
bull Inflammation
The answer may lie in complex interactions between multiple components of susceptibility This may make it very difficult to show a direct causal relationship between periodontal disease and systemic conditions
Thank you
KarenFNovakuthtmcedu
References Dasanayake AP1 Chhun N Tanner AC Craig RG Lee MJ Moore AF Norman RG J Dent Res 2008 Periodontal pathogens and gestational diabetes mellitus 2008 Apr87(4)328-33 Xiong X1 Elkind-Hirsch KE Vastardis S Delarosa RL Pridjian G Buekens P Periodontal disease is associated with gestational diabetes mellitus a case-control study J Periodontol 2009 Nov80(11)1742-9 Ruiz DR1 Romito GA Dib SA Periodontal disease in gestational and type 1 diabetes mellitus pregnant women Oral Dis 2011 Jul17(5)515-21 Xiong X Elkind-Hirsch KE Xie Y Delarosa R Maney P Pridjian G Buekens P Periodontal disease as a potential risk factor for the development of diabetes in women with a prior history of gestational diabetes mellitus J Public Health Dent 2013 Winter73(1)41-9 Michalowicz BS Hodges JS DiANgelis AJ Lupo VR Novak MJ Ferguson JE et al Treatment of periodontal disease and the risk of preterm birth N Engl J Med 2006 3551885-94 Offenbacher S Beck JD Jared HL Maaureilllo SM Mendoza LC Couper DJ et al Effects of periodontal therapy on rate or preterm delivery a randomized controlled trial Maternal Oral Therapy to Reduce Obstetric Risk (MOTOR) Investigators Obstet Gynecol 2009 114551-9 Committee on Health Care for Underserved Women Committee Opinion Oral health care during pregnancy and through the lifespan 2013 122417-422
Conclusion bull Women in this study with the combination of GDM
plus periodontal disease had
ndash a 23-fold greater risk for developing adverse maternal outcomes than women with either GDM or periodontal disease alone
Fig 1
Gestational Diabetes Mellitus Periodontal Disease
Negative Maternal and Fetal Outcomes
Combined Effect
Periodontal Variable
Adverse pregnancy outcomes
n=130
No adverse pregnancy outcomes
n=176
P- value (Wilcoxon test)
Plaque index 056 (019) 053 (017) 008
Probing depth 28 (051) 27 (056) 001
Clinical attachment loss
063 (055) 062 (055) 084
Calculus (0-3) 044 (037) 039 (037) 017
Bleeding (0-3) 036 (030) 033 (031) 007
Case Control Comparison
Periodontal Variable
GDM + n=153
GDM ndash n=153
(P- value) (Wilcoxon
test)
Plaque index 055 (017) 053 (019) 026
Probing depth 28 (057) 27 (049) 008
Clinical attachment loss
066 (056) 058 (054) 021
Calculus (0-3) 044 (037) 039 (037) 020
Bleeding (0-3) 037 (031) 032 (030) 021
Case Control Comparison
Conclusions bull Probing pocket depth independent of GDM
status was a significant predictor of adverse pregnancy outcomes (p=001)
bull Bleeding on probing was related to adverse pregnancy outcomes (p=007)
bull GDM status was related to probing pocket depth (p=008)
Odds Ratios for Adverse Fetal Outcomes
Contrasts for PD and GDM status Odds Ratio 95 CI
PD+ GDM+ vs PD- GDM- 142 064 314
PD+ GDM+ vs PD- GDM+ 147 066 327
PD+ GDM+ vs PD+ GDM- 119 058 242
Multivariable logistic regression GEE adjusted for smoking and calculus Variables used for matching were not used as covariates in the GEE matched analysis regression
modeling These included age raceethnicity and gestational age at enrollment
Conclusion bull Women in this study with the combination of GDM
plus periodontal disease had
ndash no greater risk for adverse fetal outcomes than women with either GDM or periodontal disease alone
Conclusions bull Women in this study with the combination of GDM
plus periodontal disease had
ndash a 23-fold greater risk for developing adverse maternal outcomes than women with either GDM or periodontal disease alone bull Probing pocket depth independent of GDM status was a
significant predictor of adverse pregnancy outcomes (p=001)
bull Bleeding on probing was related to adverse pregnancy outcomes (p=007)
bull GDM status was related to probing pocket depth (p=008)
ndash no greater risk for adverse fetal outcomes than women with either GDM or periodontal disease alone
Exploring the possible biology of an oral-systemic link
ldquoOral health is integral to general healthrdquo
A ldquosilent epidemic of oral diseases is affecting our most vulnerable citizensrdquo
How could periodontal disease contribute to systemic
conditions
Defining periodontal disease
bull An inflammatory disease that is initiated by the
accumulation of Gram-negative bacteria around the
teeth and gums
Potential mechanisms
bull Dissemination of periodontal infection
bull Dissemination of periodontal inflammation
Is there evidence that periodontal bacteria play a major role
bull ldquoGuilt by associationrdquo
ndash Periodontal bacteria rarely found in systemic organs
ndash Case of fetal demise due to oral Fusobacterial infection extremely rare
ndash No cases of stroke or myocardial infarction due to periodontal infection
Letrsquos look at inflammation as a potential culprit
Inflammation
bull Initiates the host response to challenge
bull Brings immune cells and molecules to the site of challenge
bull A tightly regulated mechanism
bull When dysregulated leads to pathology
ndash Genetic (polymorphisms in gene structure)
ndash Environmental (smoking stress diet)
ndash Systemic (obesity type 2 diabetes hormonal)
Including
Periodontal disease
Periodontal disease and systemic disease
bull Risk indicator or risk factor
ndash Risk indicator ndash periodontal disease and the systemic condition share common etiologies
ndash Risk factor ndash oral infectioninflammation contributes to the genesis of the systemic condition Remove periodontal disease and the systemic condition improves
What is the evidence
bull Cross sectional studies
ndash periodontal disease may be a risk indicator for systemic inflammatory conditions in certain populations
ndash failed to show a causal effect suggesting that periodontal disease is not a risk factor for systemic disease
What is the answer
bull Periodontitis and systemic inflammatory conditions have complex etiologies
bull Influenced by
ndash Socio-economic status
ndash Lifestyle choicesbehaviors
bull Diet stress smoking drug abuse
ndash Genetics family history a good predictor
bull Infection
bull Inflammation
The answer may lie in complex interactions between multiple components of susceptibility This may make it very difficult to show a direct causal relationship between periodontal disease and systemic conditions
Thank you
KarenFNovakuthtmcedu
References Dasanayake AP1 Chhun N Tanner AC Craig RG Lee MJ Moore AF Norman RG J Dent Res 2008 Periodontal pathogens and gestational diabetes mellitus 2008 Apr87(4)328-33 Xiong X1 Elkind-Hirsch KE Vastardis S Delarosa RL Pridjian G Buekens P Periodontal disease is associated with gestational diabetes mellitus a case-control study J Periodontol 2009 Nov80(11)1742-9 Ruiz DR1 Romito GA Dib SA Periodontal disease in gestational and type 1 diabetes mellitus pregnant women Oral Dis 2011 Jul17(5)515-21 Xiong X Elkind-Hirsch KE Xie Y Delarosa R Maney P Pridjian G Buekens P Periodontal disease as a potential risk factor for the development of diabetes in women with a prior history of gestational diabetes mellitus J Public Health Dent 2013 Winter73(1)41-9 Michalowicz BS Hodges JS DiANgelis AJ Lupo VR Novak MJ Ferguson JE et al Treatment of periodontal disease and the risk of preterm birth N Engl J Med 2006 3551885-94 Offenbacher S Beck JD Jared HL Maaureilllo SM Mendoza LC Couper DJ et al Effects of periodontal therapy on rate or preterm delivery a randomized controlled trial Maternal Oral Therapy to Reduce Obstetric Risk (MOTOR) Investigators Obstet Gynecol 2009 114551-9 Committee on Health Care for Underserved Women Committee Opinion Oral health care during pregnancy and through the lifespan 2013 122417-422
Periodontal Variable
Adverse pregnancy outcomes
n=130
No adverse pregnancy outcomes
n=176
P- value (Wilcoxon test)
Plaque index 056 (019) 053 (017) 008
Probing depth 28 (051) 27 (056) 001
Clinical attachment loss
063 (055) 062 (055) 084
Calculus (0-3) 044 (037) 039 (037) 017
Bleeding (0-3) 036 (030) 033 (031) 007
Case Control Comparison
Periodontal Variable
GDM + n=153
GDM ndash n=153
(P- value) (Wilcoxon
test)
Plaque index 055 (017) 053 (019) 026
Probing depth 28 (057) 27 (049) 008
Clinical attachment loss
066 (056) 058 (054) 021
Calculus (0-3) 044 (037) 039 (037) 020
Bleeding (0-3) 037 (031) 032 (030) 021
Case Control Comparison
Conclusions bull Probing pocket depth independent of GDM
status was a significant predictor of adverse pregnancy outcomes (p=001)
bull Bleeding on probing was related to adverse pregnancy outcomes (p=007)
bull GDM status was related to probing pocket depth (p=008)
Odds Ratios for Adverse Fetal Outcomes
Contrasts for PD and GDM status Odds Ratio 95 CI
PD+ GDM+ vs PD- GDM- 142 064 314
PD+ GDM+ vs PD- GDM+ 147 066 327
PD+ GDM+ vs PD+ GDM- 119 058 242
Multivariable logistic regression GEE adjusted for smoking and calculus Variables used for matching were not used as covariates in the GEE matched analysis regression
modeling These included age raceethnicity and gestational age at enrollment
Conclusion bull Women in this study with the combination of GDM
plus periodontal disease had
ndash no greater risk for adverse fetal outcomes than women with either GDM or periodontal disease alone
Conclusions bull Women in this study with the combination of GDM
plus periodontal disease had
ndash a 23-fold greater risk for developing adverse maternal outcomes than women with either GDM or periodontal disease alone bull Probing pocket depth independent of GDM status was a
significant predictor of adverse pregnancy outcomes (p=001)
bull Bleeding on probing was related to adverse pregnancy outcomes (p=007)
bull GDM status was related to probing pocket depth (p=008)
ndash no greater risk for adverse fetal outcomes than women with either GDM or periodontal disease alone
Exploring the possible biology of an oral-systemic link
ldquoOral health is integral to general healthrdquo
A ldquosilent epidemic of oral diseases is affecting our most vulnerable citizensrdquo
How could periodontal disease contribute to systemic
conditions
Defining periodontal disease
bull An inflammatory disease that is initiated by the
accumulation of Gram-negative bacteria around the
teeth and gums
Potential mechanisms
bull Dissemination of periodontal infection
bull Dissemination of periodontal inflammation
Is there evidence that periodontal bacteria play a major role
bull ldquoGuilt by associationrdquo
ndash Periodontal bacteria rarely found in systemic organs
ndash Case of fetal demise due to oral Fusobacterial infection extremely rare
ndash No cases of stroke or myocardial infarction due to periodontal infection
Letrsquos look at inflammation as a potential culprit
Inflammation
bull Initiates the host response to challenge
bull Brings immune cells and molecules to the site of challenge
bull A tightly regulated mechanism
bull When dysregulated leads to pathology
ndash Genetic (polymorphisms in gene structure)
ndash Environmental (smoking stress diet)
ndash Systemic (obesity type 2 diabetes hormonal)
Including
Periodontal disease
Periodontal disease and systemic disease
bull Risk indicator or risk factor
ndash Risk indicator ndash periodontal disease and the systemic condition share common etiologies
ndash Risk factor ndash oral infectioninflammation contributes to the genesis of the systemic condition Remove periodontal disease and the systemic condition improves
What is the evidence
bull Cross sectional studies
ndash periodontal disease may be a risk indicator for systemic inflammatory conditions in certain populations
ndash failed to show a causal effect suggesting that periodontal disease is not a risk factor for systemic disease
What is the answer
bull Periodontitis and systemic inflammatory conditions have complex etiologies
bull Influenced by
ndash Socio-economic status
ndash Lifestyle choicesbehaviors
bull Diet stress smoking drug abuse
ndash Genetics family history a good predictor
bull Infection
bull Inflammation
The answer may lie in complex interactions between multiple components of susceptibility This may make it very difficult to show a direct causal relationship between periodontal disease and systemic conditions
Thank you
KarenFNovakuthtmcedu
References Dasanayake AP1 Chhun N Tanner AC Craig RG Lee MJ Moore AF Norman RG J Dent Res 2008 Periodontal pathogens and gestational diabetes mellitus 2008 Apr87(4)328-33 Xiong X1 Elkind-Hirsch KE Vastardis S Delarosa RL Pridjian G Buekens P Periodontal disease is associated with gestational diabetes mellitus a case-control study J Periodontol 2009 Nov80(11)1742-9 Ruiz DR1 Romito GA Dib SA Periodontal disease in gestational and type 1 diabetes mellitus pregnant women Oral Dis 2011 Jul17(5)515-21 Xiong X Elkind-Hirsch KE Xie Y Delarosa R Maney P Pridjian G Buekens P Periodontal disease as a potential risk factor for the development of diabetes in women with a prior history of gestational diabetes mellitus J Public Health Dent 2013 Winter73(1)41-9 Michalowicz BS Hodges JS DiANgelis AJ Lupo VR Novak MJ Ferguson JE et al Treatment of periodontal disease and the risk of preterm birth N Engl J Med 2006 3551885-94 Offenbacher S Beck JD Jared HL Maaureilllo SM Mendoza LC Couper DJ et al Effects of periodontal therapy on rate or preterm delivery a randomized controlled trial Maternal Oral Therapy to Reduce Obstetric Risk (MOTOR) Investigators Obstet Gynecol 2009 114551-9 Committee on Health Care for Underserved Women Committee Opinion Oral health care during pregnancy and through the lifespan 2013 122417-422
Periodontal Variable
GDM + n=153
GDM ndash n=153
(P- value) (Wilcoxon
test)
Plaque index 055 (017) 053 (019) 026
Probing depth 28 (057) 27 (049) 008
Clinical attachment loss
066 (056) 058 (054) 021
Calculus (0-3) 044 (037) 039 (037) 020
Bleeding (0-3) 037 (031) 032 (030) 021
Case Control Comparison
Conclusions bull Probing pocket depth independent of GDM
status was a significant predictor of adverse pregnancy outcomes (p=001)
bull Bleeding on probing was related to adverse pregnancy outcomes (p=007)
bull GDM status was related to probing pocket depth (p=008)
Odds Ratios for Adverse Fetal Outcomes
Contrasts for PD and GDM status Odds Ratio 95 CI
PD+ GDM+ vs PD- GDM- 142 064 314
PD+ GDM+ vs PD- GDM+ 147 066 327
PD+ GDM+ vs PD+ GDM- 119 058 242
Multivariable logistic regression GEE adjusted for smoking and calculus Variables used for matching were not used as covariates in the GEE matched analysis regression
modeling These included age raceethnicity and gestational age at enrollment
Conclusion bull Women in this study with the combination of GDM
plus periodontal disease had
ndash no greater risk for adverse fetal outcomes than women with either GDM or periodontal disease alone
Conclusions bull Women in this study with the combination of GDM
plus periodontal disease had
ndash a 23-fold greater risk for developing adverse maternal outcomes than women with either GDM or periodontal disease alone bull Probing pocket depth independent of GDM status was a
significant predictor of adverse pregnancy outcomes (p=001)
bull Bleeding on probing was related to adverse pregnancy outcomes (p=007)
bull GDM status was related to probing pocket depth (p=008)
ndash no greater risk for adverse fetal outcomes than women with either GDM or periodontal disease alone
Exploring the possible biology of an oral-systemic link
ldquoOral health is integral to general healthrdquo
A ldquosilent epidemic of oral diseases is affecting our most vulnerable citizensrdquo
How could periodontal disease contribute to systemic
conditions
Defining periodontal disease
bull An inflammatory disease that is initiated by the
accumulation of Gram-negative bacteria around the
teeth and gums
Potential mechanisms
bull Dissemination of periodontal infection
bull Dissemination of periodontal inflammation
Is there evidence that periodontal bacteria play a major role
bull ldquoGuilt by associationrdquo
ndash Periodontal bacteria rarely found in systemic organs
ndash Case of fetal demise due to oral Fusobacterial infection extremely rare
ndash No cases of stroke or myocardial infarction due to periodontal infection
Letrsquos look at inflammation as a potential culprit
Inflammation
bull Initiates the host response to challenge
bull Brings immune cells and molecules to the site of challenge
bull A tightly regulated mechanism
bull When dysregulated leads to pathology
ndash Genetic (polymorphisms in gene structure)
ndash Environmental (smoking stress diet)
ndash Systemic (obesity type 2 diabetes hormonal)
Including
Periodontal disease
Periodontal disease and systemic disease
bull Risk indicator or risk factor
ndash Risk indicator ndash periodontal disease and the systemic condition share common etiologies
ndash Risk factor ndash oral infectioninflammation contributes to the genesis of the systemic condition Remove periodontal disease and the systemic condition improves
What is the evidence
bull Cross sectional studies
ndash periodontal disease may be a risk indicator for systemic inflammatory conditions in certain populations
ndash failed to show a causal effect suggesting that periodontal disease is not a risk factor for systemic disease
What is the answer
bull Periodontitis and systemic inflammatory conditions have complex etiologies
bull Influenced by
ndash Socio-economic status
ndash Lifestyle choicesbehaviors
bull Diet stress smoking drug abuse
ndash Genetics family history a good predictor
bull Infection
bull Inflammation
The answer may lie in complex interactions between multiple components of susceptibility This may make it very difficult to show a direct causal relationship between periodontal disease and systemic conditions
Thank you
KarenFNovakuthtmcedu
References Dasanayake AP1 Chhun N Tanner AC Craig RG Lee MJ Moore AF Norman RG J Dent Res 2008 Periodontal pathogens and gestational diabetes mellitus 2008 Apr87(4)328-33 Xiong X1 Elkind-Hirsch KE Vastardis S Delarosa RL Pridjian G Buekens P Periodontal disease is associated with gestational diabetes mellitus a case-control study J Periodontol 2009 Nov80(11)1742-9 Ruiz DR1 Romito GA Dib SA Periodontal disease in gestational and type 1 diabetes mellitus pregnant women Oral Dis 2011 Jul17(5)515-21 Xiong X Elkind-Hirsch KE Xie Y Delarosa R Maney P Pridjian G Buekens P Periodontal disease as a potential risk factor for the development of diabetes in women with a prior history of gestational diabetes mellitus J Public Health Dent 2013 Winter73(1)41-9 Michalowicz BS Hodges JS DiANgelis AJ Lupo VR Novak MJ Ferguson JE et al Treatment of periodontal disease and the risk of preterm birth N Engl J Med 2006 3551885-94 Offenbacher S Beck JD Jared HL Maaureilllo SM Mendoza LC Couper DJ et al Effects of periodontal therapy on rate or preterm delivery a randomized controlled trial Maternal Oral Therapy to Reduce Obstetric Risk (MOTOR) Investigators Obstet Gynecol 2009 114551-9 Committee on Health Care for Underserved Women Committee Opinion Oral health care during pregnancy and through the lifespan 2013 122417-422
Conclusions bull Probing pocket depth independent of GDM
status was a significant predictor of adverse pregnancy outcomes (p=001)
bull Bleeding on probing was related to adverse pregnancy outcomes (p=007)
bull GDM status was related to probing pocket depth (p=008)
Odds Ratios for Adverse Fetal Outcomes
Contrasts for PD and GDM status Odds Ratio 95 CI
PD+ GDM+ vs PD- GDM- 142 064 314
PD+ GDM+ vs PD- GDM+ 147 066 327
PD+ GDM+ vs PD+ GDM- 119 058 242
Multivariable logistic regression GEE adjusted for smoking and calculus Variables used for matching were not used as covariates in the GEE matched analysis regression
modeling These included age raceethnicity and gestational age at enrollment
Conclusion bull Women in this study with the combination of GDM
plus periodontal disease had
ndash no greater risk for adverse fetal outcomes than women with either GDM or periodontal disease alone
Conclusions bull Women in this study with the combination of GDM
plus periodontal disease had
ndash a 23-fold greater risk for developing adverse maternal outcomes than women with either GDM or periodontal disease alone bull Probing pocket depth independent of GDM status was a
significant predictor of adverse pregnancy outcomes (p=001)
bull Bleeding on probing was related to adverse pregnancy outcomes (p=007)
bull GDM status was related to probing pocket depth (p=008)
ndash no greater risk for adverse fetal outcomes than women with either GDM or periodontal disease alone
Exploring the possible biology of an oral-systemic link
ldquoOral health is integral to general healthrdquo
A ldquosilent epidemic of oral diseases is affecting our most vulnerable citizensrdquo
How could periodontal disease contribute to systemic
conditions
Defining periodontal disease
bull An inflammatory disease that is initiated by the
accumulation of Gram-negative bacteria around the
teeth and gums
Potential mechanisms
bull Dissemination of periodontal infection
bull Dissemination of periodontal inflammation
Is there evidence that periodontal bacteria play a major role
bull ldquoGuilt by associationrdquo
ndash Periodontal bacteria rarely found in systemic organs
ndash Case of fetal demise due to oral Fusobacterial infection extremely rare
ndash No cases of stroke or myocardial infarction due to periodontal infection
Letrsquos look at inflammation as a potential culprit
Inflammation
bull Initiates the host response to challenge
bull Brings immune cells and molecules to the site of challenge
bull A tightly regulated mechanism
bull When dysregulated leads to pathology
ndash Genetic (polymorphisms in gene structure)
ndash Environmental (smoking stress diet)
ndash Systemic (obesity type 2 diabetes hormonal)
Including
Periodontal disease
Periodontal disease and systemic disease
bull Risk indicator or risk factor
ndash Risk indicator ndash periodontal disease and the systemic condition share common etiologies
ndash Risk factor ndash oral infectioninflammation contributes to the genesis of the systemic condition Remove periodontal disease and the systemic condition improves
What is the evidence
bull Cross sectional studies
ndash periodontal disease may be a risk indicator for systemic inflammatory conditions in certain populations
ndash failed to show a causal effect suggesting that periodontal disease is not a risk factor for systemic disease
What is the answer
bull Periodontitis and systemic inflammatory conditions have complex etiologies
bull Influenced by
ndash Socio-economic status
ndash Lifestyle choicesbehaviors
bull Diet stress smoking drug abuse
ndash Genetics family history a good predictor
bull Infection
bull Inflammation
The answer may lie in complex interactions between multiple components of susceptibility This may make it very difficult to show a direct causal relationship between periodontal disease and systemic conditions
Thank you
KarenFNovakuthtmcedu
References Dasanayake AP1 Chhun N Tanner AC Craig RG Lee MJ Moore AF Norman RG J Dent Res 2008 Periodontal pathogens and gestational diabetes mellitus 2008 Apr87(4)328-33 Xiong X1 Elkind-Hirsch KE Vastardis S Delarosa RL Pridjian G Buekens P Periodontal disease is associated with gestational diabetes mellitus a case-control study J Periodontol 2009 Nov80(11)1742-9 Ruiz DR1 Romito GA Dib SA Periodontal disease in gestational and type 1 diabetes mellitus pregnant women Oral Dis 2011 Jul17(5)515-21 Xiong X Elkind-Hirsch KE Xie Y Delarosa R Maney P Pridjian G Buekens P Periodontal disease as a potential risk factor for the development of diabetes in women with a prior history of gestational diabetes mellitus J Public Health Dent 2013 Winter73(1)41-9 Michalowicz BS Hodges JS DiANgelis AJ Lupo VR Novak MJ Ferguson JE et al Treatment of periodontal disease and the risk of preterm birth N Engl J Med 2006 3551885-94 Offenbacher S Beck JD Jared HL Maaureilllo SM Mendoza LC Couper DJ et al Effects of periodontal therapy on rate or preterm delivery a randomized controlled trial Maternal Oral Therapy to Reduce Obstetric Risk (MOTOR) Investigators Obstet Gynecol 2009 114551-9 Committee on Health Care for Underserved Women Committee Opinion Oral health care during pregnancy and through the lifespan 2013 122417-422
Odds Ratios for Adverse Fetal Outcomes
Contrasts for PD and GDM status Odds Ratio 95 CI
PD+ GDM+ vs PD- GDM- 142 064 314
PD+ GDM+ vs PD- GDM+ 147 066 327
PD+ GDM+ vs PD+ GDM- 119 058 242
Multivariable logistic regression GEE adjusted for smoking and calculus Variables used for matching were not used as covariates in the GEE matched analysis regression
modeling These included age raceethnicity and gestational age at enrollment
Conclusion bull Women in this study with the combination of GDM
plus periodontal disease had
ndash no greater risk for adverse fetal outcomes than women with either GDM or periodontal disease alone
Conclusions bull Women in this study with the combination of GDM
plus periodontal disease had
ndash a 23-fold greater risk for developing adverse maternal outcomes than women with either GDM or periodontal disease alone bull Probing pocket depth independent of GDM status was a
significant predictor of adverse pregnancy outcomes (p=001)
bull Bleeding on probing was related to adverse pregnancy outcomes (p=007)
bull GDM status was related to probing pocket depth (p=008)
ndash no greater risk for adverse fetal outcomes than women with either GDM or periodontal disease alone
Exploring the possible biology of an oral-systemic link
ldquoOral health is integral to general healthrdquo
A ldquosilent epidemic of oral diseases is affecting our most vulnerable citizensrdquo
How could periodontal disease contribute to systemic
conditions
Defining periodontal disease
bull An inflammatory disease that is initiated by the
accumulation of Gram-negative bacteria around the
teeth and gums
Potential mechanisms
bull Dissemination of periodontal infection
bull Dissemination of periodontal inflammation
Is there evidence that periodontal bacteria play a major role
bull ldquoGuilt by associationrdquo
ndash Periodontal bacteria rarely found in systemic organs
ndash Case of fetal demise due to oral Fusobacterial infection extremely rare
ndash No cases of stroke or myocardial infarction due to periodontal infection
Letrsquos look at inflammation as a potential culprit
Inflammation
bull Initiates the host response to challenge
bull Brings immune cells and molecules to the site of challenge
bull A tightly regulated mechanism
bull When dysregulated leads to pathology
ndash Genetic (polymorphisms in gene structure)
ndash Environmental (smoking stress diet)
ndash Systemic (obesity type 2 diabetes hormonal)
Including
Periodontal disease
Periodontal disease and systemic disease
bull Risk indicator or risk factor
ndash Risk indicator ndash periodontal disease and the systemic condition share common etiologies
ndash Risk factor ndash oral infectioninflammation contributes to the genesis of the systemic condition Remove periodontal disease and the systemic condition improves
What is the evidence
bull Cross sectional studies
ndash periodontal disease may be a risk indicator for systemic inflammatory conditions in certain populations
ndash failed to show a causal effect suggesting that periodontal disease is not a risk factor for systemic disease
What is the answer
bull Periodontitis and systemic inflammatory conditions have complex etiologies
bull Influenced by
ndash Socio-economic status
ndash Lifestyle choicesbehaviors
bull Diet stress smoking drug abuse
ndash Genetics family history a good predictor
bull Infection
bull Inflammation
The answer may lie in complex interactions between multiple components of susceptibility This may make it very difficult to show a direct causal relationship between periodontal disease and systemic conditions
Thank you
KarenFNovakuthtmcedu
References Dasanayake AP1 Chhun N Tanner AC Craig RG Lee MJ Moore AF Norman RG J Dent Res 2008 Periodontal pathogens and gestational diabetes mellitus 2008 Apr87(4)328-33 Xiong X1 Elkind-Hirsch KE Vastardis S Delarosa RL Pridjian G Buekens P Periodontal disease is associated with gestational diabetes mellitus a case-control study J Periodontol 2009 Nov80(11)1742-9 Ruiz DR1 Romito GA Dib SA Periodontal disease in gestational and type 1 diabetes mellitus pregnant women Oral Dis 2011 Jul17(5)515-21 Xiong X Elkind-Hirsch KE Xie Y Delarosa R Maney P Pridjian G Buekens P Periodontal disease as a potential risk factor for the development of diabetes in women with a prior history of gestational diabetes mellitus J Public Health Dent 2013 Winter73(1)41-9 Michalowicz BS Hodges JS DiANgelis AJ Lupo VR Novak MJ Ferguson JE et al Treatment of periodontal disease and the risk of preterm birth N Engl J Med 2006 3551885-94 Offenbacher S Beck JD Jared HL Maaureilllo SM Mendoza LC Couper DJ et al Effects of periodontal therapy on rate or preterm delivery a randomized controlled trial Maternal Oral Therapy to Reduce Obstetric Risk (MOTOR) Investigators Obstet Gynecol 2009 114551-9 Committee on Health Care for Underserved Women Committee Opinion Oral health care during pregnancy and through the lifespan 2013 122417-422
Conclusion bull Women in this study with the combination of GDM
plus periodontal disease had
ndash no greater risk for adverse fetal outcomes than women with either GDM or periodontal disease alone
Conclusions bull Women in this study with the combination of GDM
plus periodontal disease had
ndash a 23-fold greater risk for developing adverse maternal outcomes than women with either GDM or periodontal disease alone bull Probing pocket depth independent of GDM status was a
significant predictor of adverse pregnancy outcomes (p=001)
bull Bleeding on probing was related to adverse pregnancy outcomes (p=007)
bull GDM status was related to probing pocket depth (p=008)
ndash no greater risk for adverse fetal outcomes than women with either GDM or periodontal disease alone
Exploring the possible biology of an oral-systemic link
ldquoOral health is integral to general healthrdquo
A ldquosilent epidemic of oral diseases is affecting our most vulnerable citizensrdquo
How could periodontal disease contribute to systemic
conditions
Defining periodontal disease
bull An inflammatory disease that is initiated by the
accumulation of Gram-negative bacteria around the
teeth and gums
Potential mechanisms
bull Dissemination of periodontal infection
bull Dissemination of periodontal inflammation
Is there evidence that periodontal bacteria play a major role
bull ldquoGuilt by associationrdquo
ndash Periodontal bacteria rarely found in systemic organs
ndash Case of fetal demise due to oral Fusobacterial infection extremely rare
ndash No cases of stroke or myocardial infarction due to periodontal infection
Letrsquos look at inflammation as a potential culprit
Inflammation
bull Initiates the host response to challenge
bull Brings immune cells and molecules to the site of challenge
bull A tightly regulated mechanism
bull When dysregulated leads to pathology
ndash Genetic (polymorphisms in gene structure)
ndash Environmental (smoking stress diet)
ndash Systemic (obesity type 2 diabetes hormonal)
Including
Periodontal disease
Periodontal disease and systemic disease
bull Risk indicator or risk factor
ndash Risk indicator ndash periodontal disease and the systemic condition share common etiologies
ndash Risk factor ndash oral infectioninflammation contributes to the genesis of the systemic condition Remove periodontal disease and the systemic condition improves
What is the evidence
bull Cross sectional studies
ndash periodontal disease may be a risk indicator for systemic inflammatory conditions in certain populations
ndash failed to show a causal effect suggesting that periodontal disease is not a risk factor for systemic disease
What is the answer
bull Periodontitis and systemic inflammatory conditions have complex etiologies
bull Influenced by
ndash Socio-economic status
ndash Lifestyle choicesbehaviors
bull Diet stress smoking drug abuse
ndash Genetics family history a good predictor
bull Infection
bull Inflammation
The answer may lie in complex interactions between multiple components of susceptibility This may make it very difficult to show a direct causal relationship between periodontal disease and systemic conditions
Thank you
KarenFNovakuthtmcedu
References Dasanayake AP1 Chhun N Tanner AC Craig RG Lee MJ Moore AF Norman RG J Dent Res 2008 Periodontal pathogens and gestational diabetes mellitus 2008 Apr87(4)328-33 Xiong X1 Elkind-Hirsch KE Vastardis S Delarosa RL Pridjian G Buekens P Periodontal disease is associated with gestational diabetes mellitus a case-control study J Periodontol 2009 Nov80(11)1742-9 Ruiz DR1 Romito GA Dib SA Periodontal disease in gestational and type 1 diabetes mellitus pregnant women Oral Dis 2011 Jul17(5)515-21 Xiong X Elkind-Hirsch KE Xie Y Delarosa R Maney P Pridjian G Buekens P Periodontal disease as a potential risk factor for the development of diabetes in women with a prior history of gestational diabetes mellitus J Public Health Dent 2013 Winter73(1)41-9 Michalowicz BS Hodges JS DiANgelis AJ Lupo VR Novak MJ Ferguson JE et al Treatment of periodontal disease and the risk of preterm birth N Engl J Med 2006 3551885-94 Offenbacher S Beck JD Jared HL Maaureilllo SM Mendoza LC Couper DJ et al Effects of periodontal therapy on rate or preterm delivery a randomized controlled trial Maternal Oral Therapy to Reduce Obstetric Risk (MOTOR) Investigators Obstet Gynecol 2009 114551-9 Committee on Health Care for Underserved Women Committee Opinion Oral health care during pregnancy and through the lifespan 2013 122417-422
Conclusions bull Women in this study with the combination of GDM
plus periodontal disease had
ndash a 23-fold greater risk for developing adverse maternal outcomes than women with either GDM or periodontal disease alone bull Probing pocket depth independent of GDM status was a
significant predictor of adverse pregnancy outcomes (p=001)
bull Bleeding on probing was related to adverse pregnancy outcomes (p=007)
bull GDM status was related to probing pocket depth (p=008)
ndash no greater risk for adverse fetal outcomes than women with either GDM or periodontal disease alone
Exploring the possible biology of an oral-systemic link
ldquoOral health is integral to general healthrdquo
A ldquosilent epidemic of oral diseases is affecting our most vulnerable citizensrdquo
How could periodontal disease contribute to systemic
conditions
Defining periodontal disease
bull An inflammatory disease that is initiated by the
accumulation of Gram-negative bacteria around the
teeth and gums
Potential mechanisms
bull Dissemination of periodontal infection
bull Dissemination of periodontal inflammation
Is there evidence that periodontal bacteria play a major role
bull ldquoGuilt by associationrdquo
ndash Periodontal bacteria rarely found in systemic organs
ndash Case of fetal demise due to oral Fusobacterial infection extremely rare
ndash No cases of stroke or myocardial infarction due to periodontal infection
Letrsquos look at inflammation as a potential culprit
Inflammation
bull Initiates the host response to challenge
bull Brings immune cells and molecules to the site of challenge
bull A tightly regulated mechanism
bull When dysregulated leads to pathology
ndash Genetic (polymorphisms in gene structure)
ndash Environmental (smoking stress diet)
ndash Systemic (obesity type 2 diabetes hormonal)
Including
Periodontal disease
Periodontal disease and systemic disease
bull Risk indicator or risk factor
ndash Risk indicator ndash periodontal disease and the systemic condition share common etiologies
ndash Risk factor ndash oral infectioninflammation contributes to the genesis of the systemic condition Remove periodontal disease and the systemic condition improves
What is the evidence
bull Cross sectional studies
ndash periodontal disease may be a risk indicator for systemic inflammatory conditions in certain populations
ndash failed to show a causal effect suggesting that periodontal disease is not a risk factor for systemic disease
What is the answer
bull Periodontitis and systemic inflammatory conditions have complex etiologies
bull Influenced by
ndash Socio-economic status
ndash Lifestyle choicesbehaviors
bull Diet stress smoking drug abuse
ndash Genetics family history a good predictor
bull Infection
bull Inflammation
The answer may lie in complex interactions between multiple components of susceptibility This may make it very difficult to show a direct causal relationship between periodontal disease and systemic conditions
Thank you
KarenFNovakuthtmcedu
References Dasanayake AP1 Chhun N Tanner AC Craig RG Lee MJ Moore AF Norman RG J Dent Res 2008 Periodontal pathogens and gestational diabetes mellitus 2008 Apr87(4)328-33 Xiong X1 Elkind-Hirsch KE Vastardis S Delarosa RL Pridjian G Buekens P Periodontal disease is associated with gestational diabetes mellitus a case-control study J Periodontol 2009 Nov80(11)1742-9 Ruiz DR1 Romito GA Dib SA Periodontal disease in gestational and type 1 diabetes mellitus pregnant women Oral Dis 2011 Jul17(5)515-21 Xiong X Elkind-Hirsch KE Xie Y Delarosa R Maney P Pridjian G Buekens P Periodontal disease as a potential risk factor for the development of diabetes in women with a prior history of gestational diabetes mellitus J Public Health Dent 2013 Winter73(1)41-9 Michalowicz BS Hodges JS DiANgelis AJ Lupo VR Novak MJ Ferguson JE et al Treatment of periodontal disease and the risk of preterm birth N Engl J Med 2006 3551885-94 Offenbacher S Beck JD Jared HL Maaureilllo SM Mendoza LC Couper DJ et al Effects of periodontal therapy on rate or preterm delivery a randomized controlled trial Maternal Oral Therapy to Reduce Obstetric Risk (MOTOR) Investigators Obstet Gynecol 2009 114551-9 Committee on Health Care for Underserved Women Committee Opinion Oral health care during pregnancy and through the lifespan 2013 122417-422
Exploring the possible biology of an oral-systemic link
ldquoOral health is integral to general healthrdquo
A ldquosilent epidemic of oral diseases is affecting our most vulnerable citizensrdquo
How could periodontal disease contribute to systemic
conditions
Defining periodontal disease
bull An inflammatory disease that is initiated by the
accumulation of Gram-negative bacteria around the
teeth and gums
Potential mechanisms
bull Dissemination of periodontal infection
bull Dissemination of periodontal inflammation
Is there evidence that periodontal bacteria play a major role
bull ldquoGuilt by associationrdquo
ndash Periodontal bacteria rarely found in systemic organs
ndash Case of fetal demise due to oral Fusobacterial infection extremely rare
ndash No cases of stroke or myocardial infarction due to periodontal infection
Letrsquos look at inflammation as a potential culprit
Inflammation
bull Initiates the host response to challenge
bull Brings immune cells and molecules to the site of challenge
bull A tightly regulated mechanism
bull When dysregulated leads to pathology
ndash Genetic (polymorphisms in gene structure)
ndash Environmental (smoking stress diet)
ndash Systemic (obesity type 2 diabetes hormonal)
Including
Periodontal disease
Periodontal disease and systemic disease
bull Risk indicator or risk factor
ndash Risk indicator ndash periodontal disease and the systemic condition share common etiologies
ndash Risk factor ndash oral infectioninflammation contributes to the genesis of the systemic condition Remove periodontal disease and the systemic condition improves
What is the evidence
bull Cross sectional studies
ndash periodontal disease may be a risk indicator for systemic inflammatory conditions in certain populations
ndash failed to show a causal effect suggesting that periodontal disease is not a risk factor for systemic disease
What is the answer
bull Periodontitis and systemic inflammatory conditions have complex etiologies
bull Influenced by
ndash Socio-economic status
ndash Lifestyle choicesbehaviors
bull Diet stress smoking drug abuse
ndash Genetics family history a good predictor
bull Infection
bull Inflammation
The answer may lie in complex interactions between multiple components of susceptibility This may make it very difficult to show a direct causal relationship between periodontal disease and systemic conditions
Thank you
KarenFNovakuthtmcedu
References Dasanayake AP1 Chhun N Tanner AC Craig RG Lee MJ Moore AF Norman RG J Dent Res 2008 Periodontal pathogens and gestational diabetes mellitus 2008 Apr87(4)328-33 Xiong X1 Elkind-Hirsch KE Vastardis S Delarosa RL Pridjian G Buekens P Periodontal disease is associated with gestational diabetes mellitus a case-control study J Periodontol 2009 Nov80(11)1742-9 Ruiz DR1 Romito GA Dib SA Periodontal disease in gestational and type 1 diabetes mellitus pregnant women Oral Dis 2011 Jul17(5)515-21 Xiong X Elkind-Hirsch KE Xie Y Delarosa R Maney P Pridjian G Buekens P Periodontal disease as a potential risk factor for the development of diabetes in women with a prior history of gestational diabetes mellitus J Public Health Dent 2013 Winter73(1)41-9 Michalowicz BS Hodges JS DiANgelis AJ Lupo VR Novak MJ Ferguson JE et al Treatment of periodontal disease and the risk of preterm birth N Engl J Med 2006 3551885-94 Offenbacher S Beck JD Jared HL Maaureilllo SM Mendoza LC Couper DJ et al Effects of periodontal therapy on rate or preterm delivery a randomized controlled trial Maternal Oral Therapy to Reduce Obstetric Risk (MOTOR) Investigators Obstet Gynecol 2009 114551-9 Committee on Health Care for Underserved Women Committee Opinion Oral health care during pregnancy and through the lifespan 2013 122417-422
ldquoOral health is integral to general healthrdquo
A ldquosilent epidemic of oral diseases is affecting our most vulnerable citizensrdquo
How could periodontal disease contribute to systemic
conditions
Defining periodontal disease
bull An inflammatory disease that is initiated by the
accumulation of Gram-negative bacteria around the
teeth and gums
Potential mechanisms
bull Dissemination of periodontal infection
bull Dissemination of periodontal inflammation
Is there evidence that periodontal bacteria play a major role
bull ldquoGuilt by associationrdquo
ndash Periodontal bacteria rarely found in systemic organs
ndash Case of fetal demise due to oral Fusobacterial infection extremely rare
ndash No cases of stroke or myocardial infarction due to periodontal infection
Letrsquos look at inflammation as a potential culprit
Inflammation
bull Initiates the host response to challenge
bull Brings immune cells and molecules to the site of challenge
bull A tightly regulated mechanism
bull When dysregulated leads to pathology
ndash Genetic (polymorphisms in gene structure)
ndash Environmental (smoking stress diet)
ndash Systemic (obesity type 2 diabetes hormonal)
Including
Periodontal disease
Periodontal disease and systemic disease
bull Risk indicator or risk factor
ndash Risk indicator ndash periodontal disease and the systemic condition share common etiologies
ndash Risk factor ndash oral infectioninflammation contributes to the genesis of the systemic condition Remove periodontal disease and the systemic condition improves
What is the evidence
bull Cross sectional studies
ndash periodontal disease may be a risk indicator for systemic inflammatory conditions in certain populations
ndash failed to show a causal effect suggesting that periodontal disease is not a risk factor for systemic disease
What is the answer
bull Periodontitis and systemic inflammatory conditions have complex etiologies
bull Influenced by
ndash Socio-economic status
ndash Lifestyle choicesbehaviors
bull Diet stress smoking drug abuse
ndash Genetics family history a good predictor
bull Infection
bull Inflammation
The answer may lie in complex interactions between multiple components of susceptibility This may make it very difficult to show a direct causal relationship between periodontal disease and systemic conditions
Thank you
KarenFNovakuthtmcedu
References Dasanayake AP1 Chhun N Tanner AC Craig RG Lee MJ Moore AF Norman RG J Dent Res 2008 Periodontal pathogens and gestational diabetes mellitus 2008 Apr87(4)328-33 Xiong X1 Elkind-Hirsch KE Vastardis S Delarosa RL Pridjian G Buekens P Periodontal disease is associated with gestational diabetes mellitus a case-control study J Periodontol 2009 Nov80(11)1742-9 Ruiz DR1 Romito GA Dib SA Periodontal disease in gestational and type 1 diabetes mellitus pregnant women Oral Dis 2011 Jul17(5)515-21 Xiong X Elkind-Hirsch KE Xie Y Delarosa R Maney P Pridjian G Buekens P Periodontal disease as a potential risk factor for the development of diabetes in women with a prior history of gestational diabetes mellitus J Public Health Dent 2013 Winter73(1)41-9 Michalowicz BS Hodges JS DiANgelis AJ Lupo VR Novak MJ Ferguson JE et al Treatment of periodontal disease and the risk of preterm birth N Engl J Med 2006 3551885-94 Offenbacher S Beck JD Jared HL Maaureilllo SM Mendoza LC Couper DJ et al Effects of periodontal therapy on rate or preterm delivery a randomized controlled trial Maternal Oral Therapy to Reduce Obstetric Risk (MOTOR) Investigators Obstet Gynecol 2009 114551-9 Committee on Health Care for Underserved Women Committee Opinion Oral health care during pregnancy and through the lifespan 2013 122417-422
How could periodontal disease contribute to systemic
conditions
Defining periodontal disease
bull An inflammatory disease that is initiated by the
accumulation of Gram-negative bacteria around the
teeth and gums
Potential mechanisms
bull Dissemination of periodontal infection
bull Dissemination of periodontal inflammation
Is there evidence that periodontal bacteria play a major role
bull ldquoGuilt by associationrdquo
ndash Periodontal bacteria rarely found in systemic organs
ndash Case of fetal demise due to oral Fusobacterial infection extremely rare
ndash No cases of stroke or myocardial infarction due to periodontal infection
Letrsquos look at inflammation as a potential culprit
Inflammation
bull Initiates the host response to challenge
bull Brings immune cells and molecules to the site of challenge
bull A tightly regulated mechanism
bull When dysregulated leads to pathology
ndash Genetic (polymorphisms in gene structure)
ndash Environmental (smoking stress diet)
ndash Systemic (obesity type 2 diabetes hormonal)
Including
Periodontal disease
Periodontal disease and systemic disease
bull Risk indicator or risk factor
ndash Risk indicator ndash periodontal disease and the systemic condition share common etiologies
ndash Risk factor ndash oral infectioninflammation contributes to the genesis of the systemic condition Remove periodontal disease and the systemic condition improves
What is the evidence
bull Cross sectional studies
ndash periodontal disease may be a risk indicator for systemic inflammatory conditions in certain populations
ndash failed to show a causal effect suggesting that periodontal disease is not a risk factor for systemic disease
What is the answer
bull Periodontitis and systemic inflammatory conditions have complex etiologies
bull Influenced by
ndash Socio-economic status
ndash Lifestyle choicesbehaviors
bull Diet stress smoking drug abuse
ndash Genetics family history a good predictor
bull Infection
bull Inflammation
The answer may lie in complex interactions between multiple components of susceptibility This may make it very difficult to show a direct causal relationship between periodontal disease and systemic conditions
Thank you
KarenFNovakuthtmcedu
References Dasanayake AP1 Chhun N Tanner AC Craig RG Lee MJ Moore AF Norman RG J Dent Res 2008 Periodontal pathogens and gestational diabetes mellitus 2008 Apr87(4)328-33 Xiong X1 Elkind-Hirsch KE Vastardis S Delarosa RL Pridjian G Buekens P Periodontal disease is associated with gestational diabetes mellitus a case-control study J Periodontol 2009 Nov80(11)1742-9 Ruiz DR1 Romito GA Dib SA Periodontal disease in gestational and type 1 diabetes mellitus pregnant women Oral Dis 2011 Jul17(5)515-21 Xiong X Elkind-Hirsch KE Xie Y Delarosa R Maney P Pridjian G Buekens P Periodontal disease as a potential risk factor for the development of diabetes in women with a prior history of gestational diabetes mellitus J Public Health Dent 2013 Winter73(1)41-9 Michalowicz BS Hodges JS DiANgelis AJ Lupo VR Novak MJ Ferguson JE et al Treatment of periodontal disease and the risk of preterm birth N Engl J Med 2006 3551885-94 Offenbacher S Beck JD Jared HL Maaureilllo SM Mendoza LC Couper DJ et al Effects of periodontal therapy on rate or preterm delivery a randomized controlled trial Maternal Oral Therapy to Reduce Obstetric Risk (MOTOR) Investigators Obstet Gynecol 2009 114551-9 Committee on Health Care for Underserved Women Committee Opinion Oral health care during pregnancy and through the lifespan 2013 122417-422
How could periodontal disease contribute to systemic
conditions
Defining periodontal disease
bull An inflammatory disease that is initiated by the
accumulation of Gram-negative bacteria around the
teeth and gums
Potential mechanisms
bull Dissemination of periodontal infection
bull Dissemination of periodontal inflammation
Is there evidence that periodontal bacteria play a major role
bull ldquoGuilt by associationrdquo
ndash Periodontal bacteria rarely found in systemic organs
ndash Case of fetal demise due to oral Fusobacterial infection extremely rare
ndash No cases of stroke or myocardial infarction due to periodontal infection
Letrsquos look at inflammation as a potential culprit
Inflammation
bull Initiates the host response to challenge
bull Brings immune cells and molecules to the site of challenge
bull A tightly regulated mechanism
bull When dysregulated leads to pathology
ndash Genetic (polymorphisms in gene structure)
ndash Environmental (smoking stress diet)
ndash Systemic (obesity type 2 diabetes hormonal)
Including
Periodontal disease
Periodontal disease and systemic disease
bull Risk indicator or risk factor
ndash Risk indicator ndash periodontal disease and the systemic condition share common etiologies
ndash Risk factor ndash oral infectioninflammation contributes to the genesis of the systemic condition Remove periodontal disease and the systemic condition improves
What is the evidence
bull Cross sectional studies
ndash periodontal disease may be a risk indicator for systemic inflammatory conditions in certain populations
ndash failed to show a causal effect suggesting that periodontal disease is not a risk factor for systemic disease
What is the answer
bull Periodontitis and systemic inflammatory conditions have complex etiologies
bull Influenced by
ndash Socio-economic status
ndash Lifestyle choicesbehaviors
bull Diet stress smoking drug abuse
ndash Genetics family history a good predictor
bull Infection
bull Inflammation
The answer may lie in complex interactions between multiple components of susceptibility This may make it very difficult to show a direct causal relationship between periodontal disease and systemic conditions
Thank you
KarenFNovakuthtmcedu
References Dasanayake AP1 Chhun N Tanner AC Craig RG Lee MJ Moore AF Norman RG J Dent Res 2008 Periodontal pathogens and gestational diabetes mellitus 2008 Apr87(4)328-33 Xiong X1 Elkind-Hirsch KE Vastardis S Delarosa RL Pridjian G Buekens P Periodontal disease is associated with gestational diabetes mellitus a case-control study J Periodontol 2009 Nov80(11)1742-9 Ruiz DR1 Romito GA Dib SA Periodontal disease in gestational and type 1 diabetes mellitus pregnant women Oral Dis 2011 Jul17(5)515-21 Xiong X Elkind-Hirsch KE Xie Y Delarosa R Maney P Pridjian G Buekens P Periodontal disease as a potential risk factor for the development of diabetes in women with a prior history of gestational diabetes mellitus J Public Health Dent 2013 Winter73(1)41-9 Michalowicz BS Hodges JS DiANgelis AJ Lupo VR Novak MJ Ferguson JE et al Treatment of periodontal disease and the risk of preterm birth N Engl J Med 2006 3551885-94 Offenbacher S Beck JD Jared HL Maaureilllo SM Mendoza LC Couper DJ et al Effects of periodontal therapy on rate or preterm delivery a randomized controlled trial Maternal Oral Therapy to Reduce Obstetric Risk (MOTOR) Investigators Obstet Gynecol 2009 114551-9 Committee on Health Care for Underserved Women Committee Opinion Oral health care during pregnancy and through the lifespan 2013 122417-422
Defining periodontal disease
bull An inflammatory disease that is initiated by the
accumulation of Gram-negative bacteria around the
teeth and gums
Potential mechanisms
bull Dissemination of periodontal infection
bull Dissemination of periodontal inflammation
Is there evidence that periodontal bacteria play a major role
bull ldquoGuilt by associationrdquo
ndash Periodontal bacteria rarely found in systemic organs
ndash Case of fetal demise due to oral Fusobacterial infection extremely rare
ndash No cases of stroke or myocardial infarction due to periodontal infection
Letrsquos look at inflammation as a potential culprit
Inflammation
bull Initiates the host response to challenge
bull Brings immune cells and molecules to the site of challenge
bull A tightly regulated mechanism
bull When dysregulated leads to pathology
ndash Genetic (polymorphisms in gene structure)
ndash Environmental (smoking stress diet)
ndash Systemic (obesity type 2 diabetes hormonal)
Including
Periodontal disease
Periodontal disease and systemic disease
bull Risk indicator or risk factor
ndash Risk indicator ndash periodontal disease and the systemic condition share common etiologies
ndash Risk factor ndash oral infectioninflammation contributes to the genesis of the systemic condition Remove periodontal disease and the systemic condition improves
What is the evidence
bull Cross sectional studies
ndash periodontal disease may be a risk indicator for systemic inflammatory conditions in certain populations
ndash failed to show a causal effect suggesting that periodontal disease is not a risk factor for systemic disease
What is the answer
bull Periodontitis and systemic inflammatory conditions have complex etiologies
bull Influenced by
ndash Socio-economic status
ndash Lifestyle choicesbehaviors
bull Diet stress smoking drug abuse
ndash Genetics family history a good predictor
bull Infection
bull Inflammation
The answer may lie in complex interactions between multiple components of susceptibility This may make it very difficult to show a direct causal relationship between periodontal disease and systemic conditions
Thank you
KarenFNovakuthtmcedu
References Dasanayake AP1 Chhun N Tanner AC Craig RG Lee MJ Moore AF Norman RG J Dent Res 2008 Periodontal pathogens and gestational diabetes mellitus 2008 Apr87(4)328-33 Xiong X1 Elkind-Hirsch KE Vastardis S Delarosa RL Pridjian G Buekens P Periodontal disease is associated with gestational diabetes mellitus a case-control study J Periodontol 2009 Nov80(11)1742-9 Ruiz DR1 Romito GA Dib SA Periodontal disease in gestational and type 1 diabetes mellitus pregnant women Oral Dis 2011 Jul17(5)515-21 Xiong X Elkind-Hirsch KE Xie Y Delarosa R Maney P Pridjian G Buekens P Periodontal disease as a potential risk factor for the development of diabetes in women with a prior history of gestational diabetes mellitus J Public Health Dent 2013 Winter73(1)41-9 Michalowicz BS Hodges JS DiANgelis AJ Lupo VR Novak MJ Ferguson JE et al Treatment of periodontal disease and the risk of preterm birth N Engl J Med 2006 3551885-94 Offenbacher S Beck JD Jared HL Maaureilllo SM Mendoza LC Couper DJ et al Effects of periodontal therapy on rate or preterm delivery a randomized controlled trial Maternal Oral Therapy to Reduce Obstetric Risk (MOTOR) Investigators Obstet Gynecol 2009 114551-9 Committee on Health Care for Underserved Women Committee Opinion Oral health care during pregnancy and through the lifespan 2013 122417-422
Potential mechanisms
bull Dissemination of periodontal infection
bull Dissemination of periodontal inflammation
Is there evidence that periodontal bacteria play a major role
bull ldquoGuilt by associationrdquo
ndash Periodontal bacteria rarely found in systemic organs
ndash Case of fetal demise due to oral Fusobacterial infection extremely rare
ndash No cases of stroke or myocardial infarction due to periodontal infection
Letrsquos look at inflammation as a potential culprit
Inflammation
bull Initiates the host response to challenge
bull Brings immune cells and molecules to the site of challenge
bull A tightly regulated mechanism
bull When dysregulated leads to pathology
ndash Genetic (polymorphisms in gene structure)
ndash Environmental (smoking stress diet)
ndash Systemic (obesity type 2 diabetes hormonal)
Including
Periodontal disease
Periodontal disease and systemic disease
bull Risk indicator or risk factor
ndash Risk indicator ndash periodontal disease and the systemic condition share common etiologies
ndash Risk factor ndash oral infectioninflammation contributes to the genesis of the systemic condition Remove periodontal disease and the systemic condition improves
What is the evidence
bull Cross sectional studies
ndash periodontal disease may be a risk indicator for systemic inflammatory conditions in certain populations
ndash failed to show a causal effect suggesting that periodontal disease is not a risk factor for systemic disease
What is the answer
bull Periodontitis and systemic inflammatory conditions have complex etiologies
bull Influenced by
ndash Socio-economic status
ndash Lifestyle choicesbehaviors
bull Diet stress smoking drug abuse
ndash Genetics family history a good predictor
bull Infection
bull Inflammation
The answer may lie in complex interactions between multiple components of susceptibility This may make it very difficult to show a direct causal relationship between periodontal disease and systemic conditions
Thank you
KarenFNovakuthtmcedu
References Dasanayake AP1 Chhun N Tanner AC Craig RG Lee MJ Moore AF Norman RG J Dent Res 2008 Periodontal pathogens and gestational diabetes mellitus 2008 Apr87(4)328-33 Xiong X1 Elkind-Hirsch KE Vastardis S Delarosa RL Pridjian G Buekens P Periodontal disease is associated with gestational diabetes mellitus a case-control study J Periodontol 2009 Nov80(11)1742-9 Ruiz DR1 Romito GA Dib SA Periodontal disease in gestational and type 1 diabetes mellitus pregnant women Oral Dis 2011 Jul17(5)515-21 Xiong X Elkind-Hirsch KE Xie Y Delarosa R Maney P Pridjian G Buekens P Periodontal disease as a potential risk factor for the development of diabetes in women with a prior history of gestational diabetes mellitus J Public Health Dent 2013 Winter73(1)41-9 Michalowicz BS Hodges JS DiANgelis AJ Lupo VR Novak MJ Ferguson JE et al Treatment of periodontal disease and the risk of preterm birth N Engl J Med 2006 3551885-94 Offenbacher S Beck JD Jared HL Maaureilllo SM Mendoza LC Couper DJ et al Effects of periodontal therapy on rate or preterm delivery a randomized controlled trial Maternal Oral Therapy to Reduce Obstetric Risk (MOTOR) Investigators Obstet Gynecol 2009 114551-9 Committee on Health Care for Underserved Women Committee Opinion Oral health care during pregnancy and through the lifespan 2013 122417-422
Is there evidence that periodontal bacteria play a major role
bull ldquoGuilt by associationrdquo
ndash Periodontal bacteria rarely found in systemic organs
ndash Case of fetal demise due to oral Fusobacterial infection extremely rare
ndash No cases of stroke or myocardial infarction due to periodontal infection
Letrsquos look at inflammation as a potential culprit
Inflammation
bull Initiates the host response to challenge
bull Brings immune cells and molecules to the site of challenge
bull A tightly regulated mechanism
bull When dysregulated leads to pathology
ndash Genetic (polymorphisms in gene structure)
ndash Environmental (smoking stress diet)
ndash Systemic (obesity type 2 diabetes hormonal)
Including
Periodontal disease
Periodontal disease and systemic disease
bull Risk indicator or risk factor
ndash Risk indicator ndash periodontal disease and the systemic condition share common etiologies
ndash Risk factor ndash oral infectioninflammation contributes to the genesis of the systemic condition Remove periodontal disease and the systemic condition improves
What is the evidence
bull Cross sectional studies
ndash periodontal disease may be a risk indicator for systemic inflammatory conditions in certain populations
ndash failed to show a causal effect suggesting that periodontal disease is not a risk factor for systemic disease
What is the answer
bull Periodontitis and systemic inflammatory conditions have complex etiologies
bull Influenced by
ndash Socio-economic status
ndash Lifestyle choicesbehaviors
bull Diet stress smoking drug abuse
ndash Genetics family history a good predictor
bull Infection
bull Inflammation
The answer may lie in complex interactions between multiple components of susceptibility This may make it very difficult to show a direct causal relationship between periodontal disease and systemic conditions
Thank you
KarenFNovakuthtmcedu
References Dasanayake AP1 Chhun N Tanner AC Craig RG Lee MJ Moore AF Norman RG J Dent Res 2008 Periodontal pathogens and gestational diabetes mellitus 2008 Apr87(4)328-33 Xiong X1 Elkind-Hirsch KE Vastardis S Delarosa RL Pridjian G Buekens P Periodontal disease is associated with gestational diabetes mellitus a case-control study J Periodontol 2009 Nov80(11)1742-9 Ruiz DR1 Romito GA Dib SA Periodontal disease in gestational and type 1 diabetes mellitus pregnant women Oral Dis 2011 Jul17(5)515-21 Xiong X Elkind-Hirsch KE Xie Y Delarosa R Maney P Pridjian G Buekens P Periodontal disease as a potential risk factor for the development of diabetes in women with a prior history of gestational diabetes mellitus J Public Health Dent 2013 Winter73(1)41-9 Michalowicz BS Hodges JS DiANgelis AJ Lupo VR Novak MJ Ferguson JE et al Treatment of periodontal disease and the risk of preterm birth N Engl J Med 2006 3551885-94 Offenbacher S Beck JD Jared HL Maaureilllo SM Mendoza LC Couper DJ et al Effects of periodontal therapy on rate or preterm delivery a randomized controlled trial Maternal Oral Therapy to Reduce Obstetric Risk (MOTOR) Investigators Obstet Gynecol 2009 114551-9 Committee on Health Care for Underserved Women Committee Opinion Oral health care during pregnancy and through the lifespan 2013 122417-422
Letrsquos look at inflammation as a potential culprit
Inflammation
bull Initiates the host response to challenge
bull Brings immune cells and molecules to the site of challenge
bull A tightly regulated mechanism
bull When dysregulated leads to pathology
ndash Genetic (polymorphisms in gene structure)
ndash Environmental (smoking stress diet)
ndash Systemic (obesity type 2 diabetes hormonal)
Including
Periodontal disease
Periodontal disease and systemic disease
bull Risk indicator or risk factor
ndash Risk indicator ndash periodontal disease and the systemic condition share common etiologies
ndash Risk factor ndash oral infectioninflammation contributes to the genesis of the systemic condition Remove periodontal disease and the systemic condition improves
What is the evidence
bull Cross sectional studies
ndash periodontal disease may be a risk indicator for systemic inflammatory conditions in certain populations
ndash failed to show a causal effect suggesting that periodontal disease is not a risk factor for systemic disease
What is the answer
bull Periodontitis and systemic inflammatory conditions have complex etiologies
bull Influenced by
ndash Socio-economic status
ndash Lifestyle choicesbehaviors
bull Diet stress smoking drug abuse
ndash Genetics family history a good predictor
bull Infection
bull Inflammation
The answer may lie in complex interactions between multiple components of susceptibility This may make it very difficult to show a direct causal relationship between periodontal disease and systemic conditions
Thank you
KarenFNovakuthtmcedu
References Dasanayake AP1 Chhun N Tanner AC Craig RG Lee MJ Moore AF Norman RG J Dent Res 2008 Periodontal pathogens and gestational diabetes mellitus 2008 Apr87(4)328-33 Xiong X1 Elkind-Hirsch KE Vastardis S Delarosa RL Pridjian G Buekens P Periodontal disease is associated with gestational diabetes mellitus a case-control study J Periodontol 2009 Nov80(11)1742-9 Ruiz DR1 Romito GA Dib SA Periodontal disease in gestational and type 1 diabetes mellitus pregnant women Oral Dis 2011 Jul17(5)515-21 Xiong X Elkind-Hirsch KE Xie Y Delarosa R Maney P Pridjian G Buekens P Periodontal disease as a potential risk factor for the development of diabetes in women with a prior history of gestational diabetes mellitus J Public Health Dent 2013 Winter73(1)41-9 Michalowicz BS Hodges JS DiANgelis AJ Lupo VR Novak MJ Ferguson JE et al Treatment of periodontal disease and the risk of preterm birth N Engl J Med 2006 3551885-94 Offenbacher S Beck JD Jared HL Maaureilllo SM Mendoza LC Couper DJ et al Effects of periodontal therapy on rate or preterm delivery a randomized controlled trial Maternal Oral Therapy to Reduce Obstetric Risk (MOTOR) Investigators Obstet Gynecol 2009 114551-9 Committee on Health Care for Underserved Women Committee Opinion Oral health care during pregnancy and through the lifespan 2013 122417-422
Inflammation
bull Initiates the host response to challenge
bull Brings immune cells and molecules to the site of challenge
bull A tightly regulated mechanism
bull When dysregulated leads to pathology
ndash Genetic (polymorphisms in gene structure)
ndash Environmental (smoking stress diet)
ndash Systemic (obesity type 2 diabetes hormonal)
Including
Periodontal disease
Periodontal disease and systemic disease
bull Risk indicator or risk factor
ndash Risk indicator ndash periodontal disease and the systemic condition share common etiologies
ndash Risk factor ndash oral infectioninflammation contributes to the genesis of the systemic condition Remove periodontal disease and the systemic condition improves
What is the evidence
bull Cross sectional studies
ndash periodontal disease may be a risk indicator for systemic inflammatory conditions in certain populations
ndash failed to show a causal effect suggesting that periodontal disease is not a risk factor for systemic disease
What is the answer
bull Periodontitis and systemic inflammatory conditions have complex etiologies
bull Influenced by
ndash Socio-economic status
ndash Lifestyle choicesbehaviors
bull Diet stress smoking drug abuse
ndash Genetics family history a good predictor
bull Infection
bull Inflammation
The answer may lie in complex interactions between multiple components of susceptibility This may make it very difficult to show a direct causal relationship between periodontal disease and systemic conditions
Thank you
KarenFNovakuthtmcedu
References Dasanayake AP1 Chhun N Tanner AC Craig RG Lee MJ Moore AF Norman RG J Dent Res 2008 Periodontal pathogens and gestational diabetes mellitus 2008 Apr87(4)328-33 Xiong X1 Elkind-Hirsch KE Vastardis S Delarosa RL Pridjian G Buekens P Periodontal disease is associated with gestational diabetes mellitus a case-control study J Periodontol 2009 Nov80(11)1742-9 Ruiz DR1 Romito GA Dib SA Periodontal disease in gestational and type 1 diabetes mellitus pregnant women Oral Dis 2011 Jul17(5)515-21 Xiong X Elkind-Hirsch KE Xie Y Delarosa R Maney P Pridjian G Buekens P Periodontal disease as a potential risk factor for the development of diabetes in women with a prior history of gestational diabetes mellitus J Public Health Dent 2013 Winter73(1)41-9 Michalowicz BS Hodges JS DiANgelis AJ Lupo VR Novak MJ Ferguson JE et al Treatment of periodontal disease and the risk of preterm birth N Engl J Med 2006 3551885-94 Offenbacher S Beck JD Jared HL Maaureilllo SM Mendoza LC Couper DJ et al Effects of periodontal therapy on rate or preterm delivery a randomized controlled trial Maternal Oral Therapy to Reduce Obstetric Risk (MOTOR) Investigators Obstet Gynecol 2009 114551-9 Committee on Health Care for Underserved Women Committee Opinion Oral health care during pregnancy and through the lifespan 2013 122417-422
Including
Periodontal disease
Periodontal disease and systemic disease
bull Risk indicator or risk factor
ndash Risk indicator ndash periodontal disease and the systemic condition share common etiologies
ndash Risk factor ndash oral infectioninflammation contributes to the genesis of the systemic condition Remove periodontal disease and the systemic condition improves
What is the evidence
bull Cross sectional studies
ndash periodontal disease may be a risk indicator for systemic inflammatory conditions in certain populations
ndash failed to show a causal effect suggesting that periodontal disease is not a risk factor for systemic disease
What is the answer
bull Periodontitis and systemic inflammatory conditions have complex etiologies
bull Influenced by
ndash Socio-economic status
ndash Lifestyle choicesbehaviors
bull Diet stress smoking drug abuse
ndash Genetics family history a good predictor
bull Infection
bull Inflammation
The answer may lie in complex interactions between multiple components of susceptibility This may make it very difficult to show a direct causal relationship between periodontal disease and systemic conditions
Thank you
KarenFNovakuthtmcedu
References Dasanayake AP1 Chhun N Tanner AC Craig RG Lee MJ Moore AF Norman RG J Dent Res 2008 Periodontal pathogens and gestational diabetes mellitus 2008 Apr87(4)328-33 Xiong X1 Elkind-Hirsch KE Vastardis S Delarosa RL Pridjian G Buekens P Periodontal disease is associated with gestational diabetes mellitus a case-control study J Periodontol 2009 Nov80(11)1742-9 Ruiz DR1 Romito GA Dib SA Periodontal disease in gestational and type 1 diabetes mellitus pregnant women Oral Dis 2011 Jul17(5)515-21 Xiong X Elkind-Hirsch KE Xie Y Delarosa R Maney P Pridjian G Buekens P Periodontal disease as a potential risk factor for the development of diabetes in women with a prior history of gestational diabetes mellitus J Public Health Dent 2013 Winter73(1)41-9 Michalowicz BS Hodges JS DiANgelis AJ Lupo VR Novak MJ Ferguson JE et al Treatment of periodontal disease and the risk of preterm birth N Engl J Med 2006 3551885-94 Offenbacher S Beck JD Jared HL Maaureilllo SM Mendoza LC Couper DJ et al Effects of periodontal therapy on rate or preterm delivery a randomized controlled trial Maternal Oral Therapy to Reduce Obstetric Risk (MOTOR) Investigators Obstet Gynecol 2009 114551-9 Committee on Health Care for Underserved Women Committee Opinion Oral health care during pregnancy and through the lifespan 2013 122417-422
Periodontal disease and systemic disease
bull Risk indicator or risk factor
ndash Risk indicator ndash periodontal disease and the systemic condition share common etiologies
ndash Risk factor ndash oral infectioninflammation contributes to the genesis of the systemic condition Remove periodontal disease and the systemic condition improves
What is the evidence
bull Cross sectional studies
ndash periodontal disease may be a risk indicator for systemic inflammatory conditions in certain populations
ndash failed to show a causal effect suggesting that periodontal disease is not a risk factor for systemic disease
What is the answer
bull Periodontitis and systemic inflammatory conditions have complex etiologies
bull Influenced by
ndash Socio-economic status
ndash Lifestyle choicesbehaviors
bull Diet stress smoking drug abuse
ndash Genetics family history a good predictor
bull Infection
bull Inflammation
The answer may lie in complex interactions between multiple components of susceptibility This may make it very difficult to show a direct causal relationship between periodontal disease and systemic conditions
Thank you
KarenFNovakuthtmcedu
References Dasanayake AP1 Chhun N Tanner AC Craig RG Lee MJ Moore AF Norman RG J Dent Res 2008 Periodontal pathogens and gestational diabetes mellitus 2008 Apr87(4)328-33 Xiong X1 Elkind-Hirsch KE Vastardis S Delarosa RL Pridjian G Buekens P Periodontal disease is associated with gestational diabetes mellitus a case-control study J Periodontol 2009 Nov80(11)1742-9 Ruiz DR1 Romito GA Dib SA Periodontal disease in gestational and type 1 diabetes mellitus pregnant women Oral Dis 2011 Jul17(5)515-21 Xiong X Elkind-Hirsch KE Xie Y Delarosa R Maney P Pridjian G Buekens P Periodontal disease as a potential risk factor for the development of diabetes in women with a prior history of gestational diabetes mellitus J Public Health Dent 2013 Winter73(1)41-9 Michalowicz BS Hodges JS DiANgelis AJ Lupo VR Novak MJ Ferguson JE et al Treatment of periodontal disease and the risk of preterm birth N Engl J Med 2006 3551885-94 Offenbacher S Beck JD Jared HL Maaureilllo SM Mendoza LC Couper DJ et al Effects of periodontal therapy on rate or preterm delivery a randomized controlled trial Maternal Oral Therapy to Reduce Obstetric Risk (MOTOR) Investigators Obstet Gynecol 2009 114551-9 Committee on Health Care for Underserved Women Committee Opinion Oral health care during pregnancy and through the lifespan 2013 122417-422
What is the evidence
bull Cross sectional studies
ndash periodontal disease may be a risk indicator for systemic inflammatory conditions in certain populations
ndash failed to show a causal effect suggesting that periodontal disease is not a risk factor for systemic disease
What is the answer
bull Periodontitis and systemic inflammatory conditions have complex etiologies
bull Influenced by
ndash Socio-economic status
ndash Lifestyle choicesbehaviors
bull Diet stress smoking drug abuse
ndash Genetics family history a good predictor
bull Infection
bull Inflammation
The answer may lie in complex interactions between multiple components of susceptibility This may make it very difficult to show a direct causal relationship between periodontal disease and systemic conditions
Thank you
KarenFNovakuthtmcedu
References Dasanayake AP1 Chhun N Tanner AC Craig RG Lee MJ Moore AF Norman RG J Dent Res 2008 Periodontal pathogens and gestational diabetes mellitus 2008 Apr87(4)328-33 Xiong X1 Elkind-Hirsch KE Vastardis S Delarosa RL Pridjian G Buekens P Periodontal disease is associated with gestational diabetes mellitus a case-control study J Periodontol 2009 Nov80(11)1742-9 Ruiz DR1 Romito GA Dib SA Periodontal disease in gestational and type 1 diabetes mellitus pregnant women Oral Dis 2011 Jul17(5)515-21 Xiong X Elkind-Hirsch KE Xie Y Delarosa R Maney P Pridjian G Buekens P Periodontal disease as a potential risk factor for the development of diabetes in women with a prior history of gestational diabetes mellitus J Public Health Dent 2013 Winter73(1)41-9 Michalowicz BS Hodges JS DiANgelis AJ Lupo VR Novak MJ Ferguson JE et al Treatment of periodontal disease and the risk of preterm birth N Engl J Med 2006 3551885-94 Offenbacher S Beck JD Jared HL Maaureilllo SM Mendoza LC Couper DJ et al Effects of periodontal therapy on rate or preterm delivery a randomized controlled trial Maternal Oral Therapy to Reduce Obstetric Risk (MOTOR) Investigators Obstet Gynecol 2009 114551-9 Committee on Health Care for Underserved Women Committee Opinion Oral health care during pregnancy and through the lifespan 2013 122417-422
What is the answer
bull Periodontitis and systemic inflammatory conditions have complex etiologies
bull Influenced by
ndash Socio-economic status
ndash Lifestyle choicesbehaviors
bull Diet stress smoking drug abuse
ndash Genetics family history a good predictor
bull Infection
bull Inflammation
The answer may lie in complex interactions between multiple components of susceptibility This may make it very difficult to show a direct causal relationship between periodontal disease and systemic conditions
Thank you
KarenFNovakuthtmcedu
References Dasanayake AP1 Chhun N Tanner AC Craig RG Lee MJ Moore AF Norman RG J Dent Res 2008 Periodontal pathogens and gestational diabetes mellitus 2008 Apr87(4)328-33 Xiong X1 Elkind-Hirsch KE Vastardis S Delarosa RL Pridjian G Buekens P Periodontal disease is associated with gestational diabetes mellitus a case-control study J Periodontol 2009 Nov80(11)1742-9 Ruiz DR1 Romito GA Dib SA Periodontal disease in gestational and type 1 diabetes mellitus pregnant women Oral Dis 2011 Jul17(5)515-21 Xiong X Elkind-Hirsch KE Xie Y Delarosa R Maney P Pridjian G Buekens P Periodontal disease as a potential risk factor for the development of diabetes in women with a prior history of gestational diabetes mellitus J Public Health Dent 2013 Winter73(1)41-9 Michalowicz BS Hodges JS DiANgelis AJ Lupo VR Novak MJ Ferguson JE et al Treatment of periodontal disease and the risk of preterm birth N Engl J Med 2006 3551885-94 Offenbacher S Beck JD Jared HL Maaureilllo SM Mendoza LC Couper DJ et al Effects of periodontal therapy on rate or preterm delivery a randomized controlled trial Maternal Oral Therapy to Reduce Obstetric Risk (MOTOR) Investigators Obstet Gynecol 2009 114551-9 Committee on Health Care for Underserved Women Committee Opinion Oral health care during pregnancy and through the lifespan 2013 122417-422
The answer may lie in complex interactions between multiple components of susceptibility This may make it very difficult to show a direct causal relationship between periodontal disease and systemic conditions
Thank you
KarenFNovakuthtmcedu
References Dasanayake AP1 Chhun N Tanner AC Craig RG Lee MJ Moore AF Norman RG J Dent Res 2008 Periodontal pathogens and gestational diabetes mellitus 2008 Apr87(4)328-33 Xiong X1 Elkind-Hirsch KE Vastardis S Delarosa RL Pridjian G Buekens P Periodontal disease is associated with gestational diabetes mellitus a case-control study J Periodontol 2009 Nov80(11)1742-9 Ruiz DR1 Romito GA Dib SA Periodontal disease in gestational and type 1 diabetes mellitus pregnant women Oral Dis 2011 Jul17(5)515-21 Xiong X Elkind-Hirsch KE Xie Y Delarosa R Maney P Pridjian G Buekens P Periodontal disease as a potential risk factor for the development of diabetes in women with a prior history of gestational diabetes mellitus J Public Health Dent 2013 Winter73(1)41-9 Michalowicz BS Hodges JS DiANgelis AJ Lupo VR Novak MJ Ferguson JE et al Treatment of periodontal disease and the risk of preterm birth N Engl J Med 2006 3551885-94 Offenbacher S Beck JD Jared HL Maaureilllo SM Mendoza LC Couper DJ et al Effects of periodontal therapy on rate or preterm delivery a randomized controlled trial Maternal Oral Therapy to Reduce Obstetric Risk (MOTOR) Investigators Obstet Gynecol 2009 114551-9 Committee on Health Care for Underserved Women Committee Opinion Oral health care during pregnancy and through the lifespan 2013 122417-422
Thank you
KarenFNovakuthtmcedu
References Dasanayake AP1 Chhun N Tanner AC Craig RG Lee MJ Moore AF Norman RG J Dent Res 2008 Periodontal pathogens and gestational diabetes mellitus 2008 Apr87(4)328-33 Xiong X1 Elkind-Hirsch KE Vastardis S Delarosa RL Pridjian G Buekens P Periodontal disease is associated with gestational diabetes mellitus a case-control study J Periodontol 2009 Nov80(11)1742-9 Ruiz DR1 Romito GA Dib SA Periodontal disease in gestational and type 1 diabetes mellitus pregnant women Oral Dis 2011 Jul17(5)515-21 Xiong X Elkind-Hirsch KE Xie Y Delarosa R Maney P Pridjian G Buekens P Periodontal disease as a potential risk factor for the development of diabetes in women with a prior history of gestational diabetes mellitus J Public Health Dent 2013 Winter73(1)41-9 Michalowicz BS Hodges JS DiANgelis AJ Lupo VR Novak MJ Ferguson JE et al Treatment of periodontal disease and the risk of preterm birth N Engl J Med 2006 3551885-94 Offenbacher S Beck JD Jared HL Maaureilllo SM Mendoza LC Couper DJ et al Effects of periodontal therapy on rate or preterm delivery a randomized controlled trial Maternal Oral Therapy to Reduce Obstetric Risk (MOTOR) Investigators Obstet Gynecol 2009 114551-9 Committee on Health Care for Underserved Women Committee Opinion Oral health care during pregnancy and through the lifespan 2013 122417-422
References Dasanayake AP1 Chhun N Tanner AC Craig RG Lee MJ Moore AF Norman RG J Dent Res 2008 Periodontal pathogens and gestational diabetes mellitus 2008 Apr87(4)328-33 Xiong X1 Elkind-Hirsch KE Vastardis S Delarosa RL Pridjian G Buekens P Periodontal disease is associated with gestational diabetes mellitus a case-control study J Periodontol 2009 Nov80(11)1742-9 Ruiz DR1 Romito GA Dib SA Periodontal disease in gestational and type 1 diabetes mellitus pregnant women Oral Dis 2011 Jul17(5)515-21 Xiong X Elkind-Hirsch KE Xie Y Delarosa R Maney P Pridjian G Buekens P Periodontal disease as a potential risk factor for the development of diabetes in women with a prior history of gestational diabetes mellitus J Public Health Dent 2013 Winter73(1)41-9 Michalowicz BS Hodges JS DiANgelis AJ Lupo VR Novak MJ Ferguson JE et al Treatment of periodontal disease and the risk of preterm birth N Engl J Med 2006 3551885-94 Offenbacher S Beck JD Jared HL Maaureilllo SM Mendoza LC Couper DJ et al Effects of periodontal therapy on rate or preterm delivery a randomized controlled trial Maternal Oral Therapy to Reduce Obstetric Risk (MOTOR) Investigators Obstet Gynecol 2009 114551-9 Committee on Health Care for Underserved Women Committee Opinion Oral health care during pregnancy and through the lifespan 2013 122417-422