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ORIGINAL Kothiwale ARTICLE et al Periodontal Disease as a Potential Risk Factor for Low Birth Weight and Reduced Matern...

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ORIGINAL Kothiwale ARTICLE et al

Periodontal Disease as a Potential Risk Factor for Low Birth Weight and Reduced Maternal Haemoglobin Levels Shaila V. Kothiwalea/ Babasaheb R. Desaib/Veerappa A. Kothiwalec/ Megha Gandhid/Savita Konine Purpose: To investigate the association between maternal periodontal disease and its effect on haemoglobin levels and low birth weight infants. Materials and Methods: This observational study included 770 mothers. Data regarding the periodontal status, pregnancy outcome variables, haemoglobin levels (Hb%) and other factors that may contribute to adverse pregnancy outcomes were collected. The data were analysed using the chi-square test and univariate logistic regression analysis. Results: Factors such as literacy (P = 0.002), adverse oral habits (P < 0.001), dental health negligence (P < 0.001), obstetric history (P = 0.001) and Hb% (P < 0.001) showed a significant association with periodontal disease. The study showed only seven mothers had not received antenatal care (ANC), which reflected the awareness of ANC during pregnancy. The reduced haemoglobin levels had an association with the severity of periodontal disease. The univariate logistic regression analysis indicated that mothers with a probing pocket depth (PPD) > 6 mm (OR = 2.21, 95% CI [1.07–4.55], P = 0.032) had a higher risk of giving birth to low birth weight infants. Conclusion: Periodontitis significantly influenced low birth weight. The increase in the severity of periodontal disease was associated with an increased rate of pre-term infants. The severity of periodontitis influenced the maternal haemoglobin levels, i.e. more severe peridontitis was associated with lower haemoglobin levels. Severe anaemia and periodontal infection may have an adverse effect on pregnancy and fetal development. Key words: gestational age, haemoglobin, low birth weight, periodontal disease Oral Health Prev Dent 2014;1:83-90

Submitted for publication: 02.08.12; accepted for publication: 09.01.13

doi: 10.3290/j.ohpd.a31224

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eriodontal diseases are a group of infectious diseases caused by predominantly gram-negative, anaerobic and microaerophilic bacteria that colonise the subgingival area (Lopez et al, 2002). It is the continuous, pathogenic and inflammatory challenge which enables bacteria and their products to reach other parts of the body, resulting in a

Professor, Department of Periodontics, K.L.E. V.K. Institute of Dental Sciences, KLE University, Belgaum, India.

b

Professor and Head, Department of OBG, JN Medical College, KLE University, Belgaum, India.

c

Professor and Head, Department of General Medicine, J.N. Medical College, Belgaum, India.

d

Postgraduate Student, Department of Periodontics, K.L.E.V.K. Institute of Dental Sciences, Belgaum, India.

e

Associate Professor, Department of Obstetrics and Gynecology, M.R. Medical College, Gulbarga, India.

Correspondence: Prof. S. V. Kothiwale, Department of Periodontics, K.L.E.V.K. Institute of Dental Sciences, K.L.E. University, Belgaum, India. Tel: +91-944-882-2706. Email: [email protected]

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systemic infections (Ageuda et al, 2008). Knowledge about virulence factors of periodontal pathogenic bacteria has provided significant insights into the potential for periodontal disease to contribute to medical pathosis. A clinical study (Offenbacher et al, 1998) was conducted to test the hypothesis that periodontal infections, serving as reservoirs for gram-negative bacteria, might pose a threat to the fetoplacental unit. Those authors showed a relation between periodontal disease and pre-term infants, who are born before 37 weeks of gestation, and low birth weight infants, whose birth weight is less than 2500 grams. It was determined that mothers with periodontal infection had more than 7 times the risk of delivering a pre-term low birth weight (PLBW) infant. Extrapolation from these data suggested that 18.2% of the PLBW deliveries occurring each year might be attributable to periodontal disease. Thus, it was concluded that periodontitis represents a previously unrecognised

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and clinically important risk factor for pre-term low birth weight, which occurs as a sequela to premature rupture of membranes or pre-term labor at less than 36 completed weeks of gestation (Offenbacher et al, 1998). Lee (1983) proposed that periodontal diseases are part of chronic inflammatory diseases which result in reduced haemoglobin (Hb) levels causing anaemia of chronic disease. The anaemia of chronic disease (ACD) has been described in the literature as one of the most common forms of anaemia observed in clinical medicine. ACD is defined as the anaemia occurring in chronic infections, inflammatory conditions or neoplastic disorders that are not due to marrow deficiencies or other diseases, occurring despite the presence of adequate iron stores and vitamins (Beutler, 1988; Means et al, 1992). A study by Hutter et al (2001) concluded that periodontitis, like other chronic conditions, may tend towards anaemia, as the number of erythrocytes and levels of haemoglobin are lower in affected patients. The haemoglobin carries important nutritional elements for the mother and the fetus, needed for proper fetal development. Hence, reduced haemoglobin may be a risk factor for low birth weight infants (Singh, 2009). Thus, the objective of the current study was to determine the association between maternal periodontal diseases, haemoglobin levels and low birth weight infants.

to the antenatal care was recorded from antenatal records provided by the mother. A structured questionnaire survey was carried out to obtain information regarding literacy, adverse oral habits such as areca nut, tobacco, pan chewing and history of dental treatment. Low birth weight in this study was defined according to the international definition of low birth weight for infants adopted by the 29th World Health Assembly (1976), i.e. < 2500 g (up to and including 2499 g). Any live birth at less than 37 weeks of gestation was considered pre term as defined by the World Health Organisation (1984). Periodontal examinations were performed using the World Health Organisation (WHO) criteria. The periodontal status of the mother was recorded with a community periodontal index (CPI) probe to determine probing pocket depth (PPD) using the community periodontal index. The oral cavity was divided into sextants. One index tooth was selected from each sextant according to the WHO criteria. Examination was done on six index teeth and the highest score was recorded for the patient, based on the following scoring system: 0: healthy; 1: bleeding on probing present; 2: presence of calculus; 3: PPD 4-5 mm; 4: PPD ≥ 6 mm; X: excluded sextant (if less than 2 teeth were present).

Statistical analysis

MATERIALS AND METHODS This observational study was conducted between September 2007 and December 2009. 770 subjects were selected from the maternity ward of KLE Hospital, Belgaum, Karnataka, India, where they received free medical care. After obtaining the ethical approval to conduct the study and consent of the subjects, they were screened for periodontal condition; other data were recorded from the hospital’s birth register. Mothers within the age group of 18–35 years with a singleton pregnancy were selected for the study. Mothers with a history of systemic conditions such as diabetes, cardiovascular disorders, hypertension, urogenital tract infections, multiple pregnancies and mothers suffering from pre-eclampsia or eclampsia, gestational diabetes or severe anaemia (Hb < 7 gm%) were excluded from the study. The data regarding the mother’s age, haemoglobin levels, obstetric history, gestational age, sex and birth weight of the newborn were collected from hospital case records. Information pertaining

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Categorical variables were compared using the chisquare (r2) test. Univariate logistic regression analysis was performed to analyse the association between periodontal status with the birth weight and gestational period. The 95% confidence interval (CI) for obtaining the odds ratio was calculated and the significance level was fixed at P = 0.05. SPSS version 12 (trial version; SPSS; Chicago, IL, USA) was used to analyse the data.

RESULTS In our study, the prevalence rate of periodontal disease as shown by the variations in the CPI scores among the different age groups was 86.3%. The remaining 13.7% of mothers had a healthy periodontium. Healthy periodontium was found in 5.1% of the illiterate mothers as compared to 18.9% in the most highly educated group (holders of academic degrees). Similarly, a higher percentage of illiterate

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Table 1 Periodontal status and literacy Literacy

Healthy

B

C

PPD ≤ 5 mm

PPD ≥ 6 mm

Total

Illiterate

4 (5.1%)

12 (15.2%)

20 (25.3%)

31 (39.2%)

12 (15.2%)

79

< 10th grade (highschool)

45 (16.9%)

47 (17.7%)

101 (38%)

54 (20.3%)

19 (7.1%)

266

Pre-university course (grades 11 and 12)

33 (11.1%)

35 (11.7%)

130 (43.6%)

75 (25.2%)

25 (8.4%)

298

23 (18.9)

11 (9.0%)

47 (38.5)

31 (25.4)

15 (12.3)

122

19

71

770

Degree Total

105

105

298

B – presence of bleeding on probing, C – presence of calculus, PPD – probing pocket depth.

Table 2 Periodontal status and adverse oral habits Habit

Healthy

No

49 (28%)

60 (34.3%)

Yes

56 (9.4%)

45 (7.6%)

Total

B

105

C

105

PPD ≤ 5mm

PPD ≥ 6mm

Total

41 (23.4%)

19 (10.9%)

6 (3.4%)

175

259 (43.5%)

174 (29.2%)

61 (10.3%)

595

300

193

67

770

PPD ≥ 6 mm

Total

39 (15.7%)

14 (5.6%)

248

209 (40%)

154 (29.5%)

53 (10.2%)

522

300

193

67

770

PPD ≤ 5 mm

PPD ≥ 6 mm

Total

20 (14.6%)

137

B – presence of bleeding on probing, C – presence of calculus, PPD – probing pocket depth.

Table 3 Periodontal status and history of dental treatment Previous dental visit

Healthy

B

C

Yes

51 (20.6%)

53 (21.4%)

No

54 (10.3%)

52 (10%)

Total

105

105

PPD ≤ 5 mm

91 (36.7%)

B – presence of bleeding on probing, C – presence of calculus, PPD – probing pocket depth.

Table 4 Periodontal status and obstetric history Obstetric history

Healthy

B

C

Spontaneous abortion

8 (5.8%)

13 (9.5%)

65 (47.4%)

31 (22.6%)

No spontaneous abortion

97 (15.3%)

92 (14.5%)

235 (37.1%)

162 (25.6%)

47 (7.4%)

633

300

193

67

770

Total

105

105

B – presence of bleeding on probing, C – presence of calculus, PPD – probing pocket depth.

mothers (15.2%) than mothers with a degree (12.3%) had a PPD ≥ 6 mm, that is, more severe periodontal destruction. Thus, the mothers’ literacy showed an association with periodontal disease (r2 = 36.778, DF = 16, P = 0.002) (Table 1). As compared to 28% of mothers with no adverse habits, only 9.4% of mothers with adverse oral habits had a healthy periodontium. The results also revealed lower CPI scores in mothers who did not have any adverse oral habits vs those who did: only 3.4% of mothers mothers without adverse oral habits had a PPD ≥ 6 mm but 10.3% of mothers with habits did so. The adverse oral habits showed a significant relationship with periodontal disease (r2 = 144.6, DF = 4, P = 0.0001) (Table 2).

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Only 5.6% of mothers who had received previous dental treatment had PPD ≥ 6 mm, whereas 10.2% of mothers without previous dental treatment had PPD ≥ 6 mm. Accordingly, there was a significant association between periodontal disease and history of dental treatment (r2 = 46.065, DF = 4, P = 0.0001) (Table 3). In the present study, 5.8% of the mothers with a history of spontaneous abortion and 15.3% of mothers with no history of spontaneous abortion had a healthy periodontium. Among the mothers with a history of spontaneous abortion, 14.6% showed PPD > 6 mm as compared to 7.4% of mothers with no history of spontaneous abortion. Periodontal disease and obstetric history showed a

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significant positive relation (r2 = 19.666, DF = 4, P = 0.001) (Table 4). The mothers were divided into 3 groups based on the haemoglobin % (≤ 10 g%, 10–11 g% and ≥ 11 g%). 14.2%, 13.7% and 13.2% of mothers showed a healthy periodontium in the three groups, respectively. The probing pocket depths < 5 mm and > 6 mm showed significant association with the haemoglobin level of the mothers (r2 = 34.009, DF = 8, P = 0.001) (Table 5). The relationship between periodontal disease and the gestational period of the mothers was not quite significant (r2 = 9.436, DF = 4, P = 0.051). There was an increase in pre-term deliveries with an increase in the severity of periodontal disease. Mothers with pre-term delivery showed a greater prevalence of higher CPI scores (27.5% had PPD ≥ 6 mm and 9.3% had PPD ≤ 5 mm) as compared to mothers with term delivery (24.2% had PPD ≥ 6, 8.5% had PPD ≤ 5 mm) (Table 6). Looking at the relationship between low birth weight and periodontal status, the prevalence of low birth weight increased with the severity of periodontal disease. When PPD was > 6 mm, the prevalence of low birth weight was significantly higher (P = 0.032) than in the healthy group (PPD < 5 mm). The study thus found a statistically significant association between periodontal disease and low birth weight (Table 7).

DISCUSSION In the present study, the relationship between the mother’s periodontal health status and birth weight of the infant agrees with other studies in other populations that found a positive correlation between periodontal disease and low birth weight (Offenbacher et al, 1996; Davenport, et al 1998, 2002; Lopez et al, 2002; Jeffcoat et al, 2003). This study’s samples were homogeneous with respect to the mothers’ socioeconomic status, as all of the participants belonged to the same stratum of the population. These mothers had free access to the primary health care centres for antenatal care during pregnancy. The periodontal health status had a positive association with literacy among the mothers. Oral health awareness among mothers could be attributed to the literacy (Table 1). 77.3% of the mothers engaged in adverse oral habits such as areca nut chewing, tobacco and pan chewing, while 22.7% did not (Table 2). The increase in the CPI scores among mothers with hab-

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its could be attributed to the adverse effects of areca nut. Areca quid chewing may be associated with a high prevalence of bleeding on probing and high clinical levels of periodontal disease (DeMiranda et al, 1986). Reactive oxygen species induced by areca nut extracts have been shown to play a role in the cytotoxic and genotoxic effect in oral cells. Areca nut extracts were found to inhibit the phagocytic activity of neutrophils in a dose-dependent manner (Hung et al, 2006) and markedly suppress T-cell activation and Th1 cytokine production (Wang et al, 2007). Dental treatment received during pregnancy decreased the prevalence of periodontal disease. This showed that the severity of periodontal diseases is reduced in individuals who have received dental treatment (Table 3). This observation could be explained by the reduction in the pathogenic microbiota by dental treatment, thereby resulting in a decrease in the inflammatory mediators. This is in accordance with other studies (Davenport et al, 1998, 2002; Mokeem et al, 2004). The prevalence of periodontal disease was increased in mothers with a history of spontaneous abortion (Table 4), which indicates inflammation of periodontal tissues of mothers may be one of the contributing factors for miscarriage. The results of the present study were in accordance with the study done by Michalowicz et al (2006). The haemoglobin levels of participants in this study showed a positive relationship with the degree of periodontal disease (Table 5). According to Singh et al (2009), severe anaemia (Hb < 7 g%) is a risk factor for LBW. In the current study, only 3 mothers suffered from severe anaemia (Hb < 7 g%), but they were excluded from the study based on our exclusion criteria. A tendency toward anaemia in patients with chronic periodontitis was also previously reported (Lainson et al, 1968; Gokhale, 2010), whereas a reverse relationship was demonstrated in data collected during the Third National Health and Nutrition Examination Survey (NHANES III), which suggested that individuals with anaemia may be more likely to have periodontal disease. The cause of anaemia of chronic disease is multifactorial, like other chronic disease conditions. Chronic periodontitis tends towards anaemia as the number of erythrocytes and levels of haemoglobin are lower in affected patients, which may be related to the elevated levels of pro-inflammatory cytokines in plasma of periodontitis patients, suppressing erythropoiesis (Hutter et al, 2001). It is

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Table 5 Periodontal status and haemoglobin levels Hb g%

Healthy

B

≤ 10

31 (14.2%)

24 (11.0%)

10 – 11

35 (13.7%)

≥ 11

39 (13.2%)

Total

105

C

PPD ≤ 5 mm

PPD ≥ 6 mm

Total

72 (32.9%)

62 (28.3%)

30 (13.7%)

219

35 (13.7%)

103 (40.4%)

67 (26.3%)

20 (7.8%)

255

46 (15.5%)

125 (42.2%)

64 (24.6%)

17 (5.7%)

296

67

770

105

300

193

B – presence of bleeding on probing, C – presence of calculus, PPD – probing pocket depth.

Table 6 Periodontal status and gestational period Odds ratio (Ref)

95% CI

P-value

105

0.97

0.52–1.79

0.919

120 (37.1%)

300

0.92

0.51–1.66

0.290

56 (27.5%)

137 (24.2%)

193

1.79

0.87–3.70

0.116

19 (9.3%)

48 (8.5%)

67

1.68

0.82–3.46

0.157

Periodontal status

Pre-term

Term

Total

Healthy

20 (9.8%)

85 (15%)

105

Bleeding

19 (9.3%)

86 (15.2%)

Calculus

90 (44.1%)

PPD6 mm

PPD – probing pocket depth, reference to healthy periodontal status.

Table 7 Periodontal status and birth weight Periodontal status

LBW

NBW

Total

Odds ratio (Ref)

95% CI

P-value

Healthy

18 (17.1%)

87 (82.9%)

105

Bleeding

21 (20%)

84 (80%)

105

0.98

0.54-1.79

0.968

Calculus

76 (25.3%)

224 (74.7%)

300

1.34

0.75-2.39

0.314

PPD < 5 mm

61 (31.6%)

132 (68.4%)

193

1.82

0.9-3.69

0.093

PPD > 6 mm

21 (31.3%)

46 (68.7%)

67

2.21

1.07-4.55

0.032

LBW – low birth weight, NBW – normal birth weight, PPD – probing pocket depth, reference to healthy periodontal status.

currently thought that pro-inflammatory cytokines from a given chronic disease process may downregulate the erythropoiesis in bone marrow (Vreugdenhil et al, 1992; Jongen-Lavencic et al, 1997). In particular, interleukin-1 (IL-1), IL-6 and tumor necrosis factor-alpha (TNF-_) have been implicated as cytokines responsible for suppressing erythropoiesis (Vreugdenhil et al, 1990; Katevas et al 1994; Neiken et al, 1995; Jongen-Lavencic et al, 1997). Another cause of anaemia may be the direct loss of blood due to bleeding from gingiva leading to reduction in the number of erythrocytes. It was observed by Lainson et al (1968) that a reduction of erythrocytes might decrease oxygen in gingival tissues, thus increasing the risk of inflammation. As early as 1935, Epstein put forth the theory that the depression in the number of erythrocytes is apparently secondary to the presence of periodontal disease. He concluded that treatment of chronic peri-

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odontal diseases resulted in the elevation of the erythrocyte count to normal or high normal levels. Periodontal disease involves various microorganisms. Among them, Porphyromonas gingivalis, commonly present, encodes a family of proteases called gingipains. Gingipains bind the erythrocytes and disrupt them by haemolysis, thereby releasing haemoglobin. Gingipains have also been shown to degrade other host iron proteins such as haptoglobin, haemopexin and transferrin. Thus, protease action appears to significantly contribute to the availability of iron for bacterial uptake. Gingival crevicular fluid also contains various haemin binding proteins, including haemoglobin, haptoglobin, haemopexin and albumin. The concentrations of haemoglobin in crevicular fluid vary depending on the degree of bleeding associated with periodontal tissue destruction. However, free haemoglobin is not available to P. gingivalis, because it is rapidly and irreversible bound by haptoglobin in crevicular fluid.

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Thus, to overcome the scavenging effect of haptoglobin, P. gingivalis must have an effective mechanism for removal of haemin from the haemoglobinhaptoglobin complex (Guo et al, 2010). A novel feature when compared to other haemin uptake loci is the presence of the hmuS gene encoding a putative chelatase. This finding suggests that the haemin uptake mechanisms in P. gingivalis may be novel compared to other bacterial iron uptake systems. The hmu locus has been found in most P. gingivalis strains, and similar loci are present in other anaerobic bacteria, including Bacteroides fragilis, Bacteroides thetaiotamicron and Prevotella intermedia. Growth of Bacteroides species is dependent on haemin, so it is probable that the P. gingivalis haemin uptake locus, hmu, encodes a universal haemin uptake system in these organisms. As such, the locus may serve as a model system for examination of haemin uptake in the Bacteroidetes phylum of microorganisms (Guo et al, 2010). Thus, P. gingivalis contains unique features which help in the utilisation of haemin for its survival. Since haemoglobin carries nutritional elements for the mother and the fetus and thus acts as an important factor for fetal development, reduction of haemoglobin levels may have an adverse effect on pregnancy and fetal development. Thus, periodontitis – being one of the risk factors for reduced haemoglobin –may be an additional risk for pregnancy (Guo et al, 2010). This study revealed a marginal correlation with periodontal status and gestational period which was seen with increased CPI scores in mothers in the pre-term group. A decrease in the gestational period showed a tendency to be correlated with an increase in the CPI scores (Table 6). The proposed link between maternal periodontal disease and preterm low birth weight infants is particularly compelling. First, PLBW has been shown to be associated with infections of the urogenital tract (Minkoff et al, 1984; Gibbs et al, 1992), which do not necessarily involve infection of the fetal-placental unit (Hiller et al, 1988). Hence, infections remote from the developing fetus have the potential to influence gestation. Second, the physiological mediators of parturition include prostaglandin E2 and TNF-_, both of which have been shown to be locally elevated (Offenbacher et al, 1986) as part of the host response to microbial challenge in periodontal diseases. In the case of TNF-_, systemic levels are also increased in periodontal patients with active disease (Moss et al, 1995). Third, despite considerable progress in describing the risk factors involved in

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PLBW, a high proportion of PLBW cases have an unexplained aetiology. The pioneering studies of Offenbacher and colleagues in this area have provided epidemiological and experimental animal model data to support an association between PLBW and periodontal bacterial infection (Davenport et al, 1998). Periodontitis due to microbial infection is a long-standing chronic inflammatory condition and could thus affect gestational period (Heimonen et al, 2000; Srinivas, 2009). During the second trimester of pregnancy, the proportion of gram-negative anaerobic bacteria in dental plaque increases with respect to aerobic bacteria. These bacteria associated with progressive disease can produce a variety of bioactive molecules that may directly affect the host (Li et al, 2000). Microbial LPS, a component of gram-negative bacteria, can activate the macrophages and other cells to synthesise and secrete a wide spectrum of molecules, including cytokines such as Il-1b, TNF-_, Il-6 and prostaglandin E2 (PGE2) as well as matrix metalloproteinases (MMPs). Thus, the periodontium can serve as a renewing reservoir for these mediators because they can reach high concentrations in the tissues in periodontitis (Offenbacher et al, 1996). Inflammatory mediators such as PGE2 are not only present in the periodontal inflammatory process but also regulate the normal physiological process of parturition, as well as pathological prematurity. Amniotic fluid levels of PGE2 rise steadily throughout pregnancy until a critical threshold level is reached to induce labor, cervical dilation, and delivery. It is believed that in any infection process, the levels of biologically active molecules such as PGE2 and TNF-_, which are usually involved in normal parturition, are raised to high levels by the infection process. Also, it has been observed histologically that the chorioamnion is often inflamed, even in the absence of any bacterial infection in the vagina (vaginosis) or cervical area. This suggests that distant sites of infection or sepsis may be targeting the placental membranes (Cox et al, 1988; Romero et al, 2002). These findings suggest that perhaps the infected periodontium represents an endocrine-like source of potentially deleterious cytokines and lipid mediators, and an underlying hyper-responsive inflammatory trait may place an individual at risk for both more severe periodontitis and pre-term birth. In our study, CPI scores decreased with term delivery and increased with pre-term delivery, which indicates that increase periodontitis-related inflammation may correlate with gestational age.

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The present study showed an increase in the CPI scores in mothers who gave birth to LBW infants, indicating that the risk of LBW increased with the severity of periodontal disease (Table 7). In a study carried out by Collins et al (1994) on golden hamsters on day 8 of pregnancy, the inoculation of live or heat-killed P. gingivalis into a previously implanted subcutaneous tissue chamber was followed by increased rates of embryo mortality and fetal growth restriction. Rates of these adverse outcomes were associated with increased levels of PGE2 and TNF-_ in the chamber fluid. Previous studies have shown that P. gingivalis is found in the amniotic fluid and placentae of pregnant women with some obstetric diseases (Michalowicz et al, 2006). P. gingivalis can also be detected in chorionic tissues of hospitalised high-risk pregnant women; in chorion-derived cells, LPS of P. gingivalis induces IL-6 and IL-8 production via tolllike receptor-2 (TLR-2) (Pradeep et al, 2011). It is generally recognised that TLR-4 is the receptor for a gram-negative bacterial LPS, including E. coli LPS, and that TLR-2 is the receptor for gram-positive bacterial peptidoglycan and lipopeptides. However, it has been shown that P. gingivalis signals through TLR-2. Thus, increased levels of P. gingivalis in chorion-derived cells may be another mechanism of elevating proinflammatory cytokine levels resulting in pre-term birth and thus low birth weight of infants (Hasegawa-Nakamura et al, 2011).

CONCLUSION The present study provides evidence that the association between periodontitis, reduced haemoglobin levels and low birth weight have a shared pathogenesis; thus, early periodontal screening – a low cost examination procedure – could predict or identify women at risk. The finding that only three of the mothers assessed suffered from severe anaemia could be attributed to the antenatal care provided to all the mothers. The screening for oral hygiene and treatment of periodontal disease in pregnant women should be mandatory in antenatal care. This would help in the prevention of LBW infants, sparing the mother and society high costs. Hence, interdisciplinary care between the obstetrician and the periodontist should be routine, as it would enhance the quality of medical and dental care being provided to our patients in the community.

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ACKNOWLEDGEMENTS We would like to thank Sri M.D. Mallapur, Statistician, and Dr. Dwiti Thanawala, Dr. Pallavi Agarwal and Dr. Laxmi Hombal for the support.

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