Abstract
Background and Aims:
In periodontal disease, pathogenic inflammatory factors hold a vital part in adverse pregnancy outcomes. In recent years, there has been a large amount of literature concerning the association between periodontal disease and adverse pregnancy outcomes such as preterm birth (PTB) and low-birth-weight baby (LBWB). In the Middle-east region, reports indicate a higher rate of adverse pregnancy outcomes, and periodontitis is believed to be one of several risk factors for adverse pregnancy outcomes. This cross-sectional, epidemiological study aimed to investigate the prevalence of periodontal diseases among pregnant women in the Qassim region and its association as a possible risk factor for adverse pregnancy outcomes.
Materials and Methodology:
This was a cross-sectional, epidemiological study of 380 pregnant women from the 8th week postconception to parturition who were attending to Maternal and Children's Hospital in Buraidah, Qassim, KSA. The data were collected through questionnaire and oral examination. Plaque scores (Silness and Loe) and gingival disease scores (Ramfjord Periodontal Disease Index [PDI]) were used to assess oral hygiene status. The questionnaire data collected included gestational age, plaque control habits, previous incidences of premature birth, and awareness of expectant mothers about periodontal disease.
Results:
Data were collected for 380 participants. Our results based on the plaque index and PDI showed that all (100%) of these 380 pregnant women suffered periodontal diseases (gingivitis 78.9% and periodontitis 21.1%). The distribution of gingivitis was the highest among 3rd trimester patients and lowest among 1st trimester patients. Mild-to-moderate types of periodontitis (4 mm–5 mm) were more prevalent among the participants compared with severe (more than 6 mm) forms of periodontitis with a higher prevalence in the 3rd trimester (7–9 months) of gestational age.
Conclusions:
A very strong significant association of pregnancy and periodontal disease in the Saudi population (Qassim Region) and periodontal disease is risk factor for PTB and LBWB for these patients.
KEYWORDS: Low-birth-weight baby, periodontal diseases, pregnancy outcomes, preterm birth
INTRODUCTION
Periodontal disease includes gingivitis (reversible gingival inflammation) and periodontitis (irreversible form of gingival inflammation with loss of tooth-supporting tissues.[1] Hormonal changes during pregnancy make the gingival tissue vulnerable to inflammation and if proper care is not taken, periodontitis may result. However, over the last two decades, the focus has shifted as periodontal disease may be the cause of adverse pregnancy outcomes. In recent years, there has been a large amount of literature concerning the link between periodontal disease and adverse pregnancy outcomes such as preterm birth (PTB) and low-birth-weight baby (LBWB).[2] Periodontal pathogenic inflammatory factors are thought to play a vital role in these adverse pregnancy outcomes.[3,4,5] The normal gestation period lasts 40 weeks. According to the World Health Organization, any childbirth earlier than the 37th week of gestation is termed PTB and LBWB denotes a new-born weighing <2500 g.[6] Any birth before 24 weeks of gestation, it is termed miscarriage. However, it can still be regarded as a very extreme form of PTB. PTB should be distinguished from early miscarriage, which is <12 weeks of gestation, and it commonly has a diverse etiology.[7]
Even though no concrete evidence to state that periodontal therapy during pregnancy will reduce adverse outcomes,[8] good oral hygiene maintenance and supportive periodontal therapy during or before pregnancy may reduce inflammation, and in turn, will help reduce the chances of adverse pregnancy outcomes.[9,10]
In Saudi Arabia, there is a high incidence of PTB and LBWB.[11,12,13,14] Previous research reports suggest an association of PTB and LBWB with consanguinity, maternal age, higher maternal body mass index, increased number of pregnancies, higher rate of cesarean sections, and low maternal health awareness education in the Middle-East region.[15,16,17] Along with other various causes, periodontal disease may also play a major role in the prevalence of adverse pregnancy outcomes. Hence, this cross-sectional epidemiological study aimed to assess the prevalence of periodontal diseases in pregnant women and their probable role as a cause of PTB and LBWB.
MATERIALS AND METHODOLOGY
Study setting and sample
The present cross-sectional study was conducted in the Maternal and Children's Hospital (MCH) in Buraidah, Qassim, KSA, in a group of pregnant women diagnosed with or without periodontal diseases. A total of 433 participants were selected using a convenience sampling methodology. Of these participants, 380 qualified for recruitment in our study as complete pregnancy outcome data. Ethical clearance was obtained from the ethical approval committee of Qasim University, and written consents were obtained from the patients who agreed to be part of the study. Permission to carry out this research was obtained from the ethical committee of the Ministry of Health, Training and Research Center of MCH Qassim, Saudi Arabia.
Demographic data
Personal information (age, gender, medical condition, and oral hygiene practices) was collected through questionnaire from the participants which consisted of closed-ended questions.
Oral examination
The clinical oral examination of the participants was performed using mouth mirrors, dental explorer, and World Health Organization (WHO) probes with proper sterilization maintained.
Periodontal assessment
The plaque index (Silness and Löe)[18] and periodontal disease index (PDI) (Ramfjord)[19] were used to determine periodontal condition. The plaque index system prompts adequate accumulation of plaque within the gingival sulcus, or the tooth and gingival margin which can be seen with the naked eye. The PDI method of assessing periodontal status includes examination of six teeth and scoring for gingivitis, calculus and plaque deposits, and depth of gingival crevice.[19] The PDI is the total of the scores for each tooth divided by the number of examined teeth: The higher the score, the more severe the periodontal disease.
The observers for clinical examinations were blinded regarding the aim of the study. Interexaminer reliability for dental examination criteria was tested by performing replica examination on 25 randomly chosen participants. The interexaminer reliability using Kappa statistics was 0.9.
Statistical analysis
Descriptive statistics were calculated in tabulated form with regard to age, gender, medical condition, and regular use of oral hygiene methods. To assess the significant difference between the variables, the Chi-square test was applied. P < 0.05 was considered statistically significant. Statistical analyses were performed using IBM-SPSS version 21 software, Armonk, NY, USA.
RESULTS
Baseline demographic and periodontal data were gathered from 433 participants. A sample of 380 pregnant women visiting the MCH Buraidah participated in the research. The periodontal status of the participants was evaluated on the basis of plaque and periodontal disease indices.
Clinical evaluation results showed that the mean plaque indices were 1.49 ± 0.61 for incisors and 1.83 ± 0.68 for molars. The plaque index distribution was higher for the participants who were 4–6 months of gestational age than those who were 1–3 months and 7–9 months of gestational age. The study results revealed that the prevalence rates of gingivitis and periodontitis amid pregnant women were 78.9% and 21.1%, respectively. Periodontal disease exhibited a higher distribution rate among those aged 26–35 years, with 46.3% gingivitis and 10.5% periodontitis [Table 1].
Table 1.
Prevalence of gingivitis and periodontitis amid the pregnant participants
| Age (years) | Gingivitis age, n (%) | Periodontitis age, n (%) | Total |
|---|---|---|---|
| 18-25 | 56 (14.7) | 8 (2.1) | 64 |
| 26-35 | 176 (46.3) | 40 (10.5) | 216 |
| 36-48 | 68 (17.9) | 32 (8.4) | 100 |
| Total (yes) | 300 (78.9) | 80 (21.1) | 380 |
The PDI results revealed a higher correlation (P = 0.000) for pregnancy with 208 participants having gingivitis and 48 having periodontitis. The distribution of gingivitis was the highest among 3rd trimester patients and lowest among 1st trimester patients [Table 2]. Mild-to-moderate types of periodontitis (4–5 mm) were more prevalent among the participants compared with severe (more than 6 mm) forms of periodontitis, with a higher prevalence in the 3rd trimester (7–9 months) of gestational age.
Table 2.
Gestational age distribution of periodontal diseases among the participants
| Gestational age (months) | Gingivitis (n) | Periodontitis (n) | Total |
|---|---|---|---|
| 1-3 | 24 | 8 | 32 |
| 4-6 | 68 | 24 | 92 |
| 7-9 | 208 | 48 | 256 |
| Total | 300 | 80 | 380 |
Questionnaire response data showed, that of the 380 patients, 68 participants (17.9%) had previous issues of premature labor, and when clinically examined, the majority of them had gingivitis (56 participants, 82.4%) and periodontitis (12 participants, 17.6%). The results concerning awareness of oral hygiene maintenance showed that, 24 (6.3%) participants brushed three times a day, followed by 188 (49.5%) participants who brushed twice daily, 156 (41.1%) participants who brushed once daily, and 12 (3.2%) participants who never brushed. No statistical significance was found between brushing time and periodontal disease (P = 0.254). The chemical mode of plaque control results showed that 24 participants (6.3%) used mouthwashes once daily, 64 (16.8%) used them twice a week, and 292 (76.8%) never used mouthwashes at all. Furthermore, participants who did not use mouthwashes had the prevalence of gingivitis and periodontitis of 61.1% and 15.8%, respectively. Hence, statistically significant variances were detected in the use of mouth wash and periodontal diseases (P < 0.05) [Table 3].
Table 3.
Distribution of periodontal disease versus oral hygiene maintenance among the participants
| Three times/day | Two times/day | 1 time/day | 0 times/day | |
|---|---|---|---|---|
| Tooth brushing | 24 | 188 | 156 | 12 |
| Mouth wash use | 0 | 64 | 24 | 292 |
|
| ||||
| Tooth brushing | Mouth wash | |||
|
|
|
|||
| Gingivitis, n (%) | Periodontitis, n (%) | Gingivitis, n (%) | Periodontitis, n (%) | |
|
| ||||
| Three times per day | 24 (6.3) | 0 | 0 | 0 |
| Two times per day | 144 (37.8) | 44 (11.5) | 56 (14.7) | 8 (2.1) |
| One time per day | 124 (32.6) | 32 (8.4) | 12 (3.2) | 12 (3.2) |
| 0 times per day | 8 (2.1) | 4 (1.2) | 232 (61.1) | 60 (15.8) |
As per the data and analysis, 92 participants (24.2%) visited dental clinics during pregnancy. Those who did not visit dental clinics had high percentages of periodontal disease (56.8% gingivitis and 18.9% periodontitis) compared with those who visited dental clinics (22.1% gingivitis and 2.1% periodontitis). There was a correlation between participants visiting dental clinics during pregnancy and periodontal diseases (P = 0.018).
DISCUSSION
In recent years, several studies have found an association among periodontal disease and adverse pregnancy outcomes,[20,21,22] while few did not.[23,24] This may emphasize the idiopathic nature or multifactorial etiology of adverse pregnancy outcomes.[25,26] Many cross-sectional and case–control reports have shown associations between periodontal status and PTB or low birth weight (LBW) alone, or PTB associated with LBW..[27,28] Mitchell-Lewis et al. observed no evidence to associate periodontitis and PTB[29] and Davenport et al. reported no evidence with entities in a mixed-race population.[30]
In the present study, the existence of periodontal disease in pregnant participants was compared with the presence of commonly recognized risk factors such as age, gestational age, oral hygiene maintenance and awareness of periodontal diseases, and its interrelationship with prematurity and LBW. The results demonstrated the possibility of high significance between periodontal disease and adverse pregnancy outcomes since the majority of participants had periodontal diseases. Our results agree with the results from previous studies.[31,32] Offenbacher et al.,(1997) reported that, mothers with periodontal disease are seven times more likely to give birth to PLBW.[33] Jeffcoat et al. observed similar results postulating that the risk of PLBW increases 4–7 fold with the severity of periodontal disease.[34] Mokeem et al. upheld the risk of delivering a PTB, and LBW increases 4 fold with an increase in periodontal disease, irrespective of the control of other risk factors such as age, and smoking.[32] In our study, there was a significant correlation between the plaque index, gingival index, and periodontal disease among the pregnant women. Middle-aged[26,27,28,29,30,31,32,33,34,35] women and 3rd trimester patients had a higher prevalence of gingivitis and periodontitis, indicating that the younger age group did not consider oral health care, especially in the 3rd trimester. This factor is vital, as increased periodontal proinflammatory cytokines and C-reactive proteins may cause premature uterine contractions, leading to premature birth.[35,36,37]
In our study, the data suggest that the majority of participants (76.8%) never used mouthwash as a chemical mode of plaque control resulting in a high percentage of periodontal disease (gingivitis 61.1% and periodontitis 15.8%), and this percentile decreased drastically (gingivitis 3.2%–14.7% and periodontitis 2.1%–3.2%) when participants used mouthwash twice or once a day. In support of these findings, Jiang revealed that the use of alcohol-free antimicrobial CPC mouth rinses in pregnancy, improved periodontal health status in the 3rd trimester. Although mouth rinsing did not have an impact on gestational age, it greatly reduced the premature rupture of uterine membranes.[38] Hence, considering that these participants with periodontal inflammation are at risk of premature birth and LBWB, it is advisable for them to use chemical plaque control agents (mouthwashes) along with mechanical plaque control methods.
According to the recommendations by the American Academy of Pediatric Dentistry for pregnant women, educating them for good plaque control measures is essential in reducing the chances of PTB and LBW babies.[39] Using the correct brushing and flossing method highly influences plaque removal and as well, educating expectant mothers about proper diet and nutrition in pregnancy will reduce excessive sugar intake and in turn prevent plaque build-up.[40] Hence, it is suggested to have a policy in maternity centres to advise all expectant mothers to compulsorily visit dentists or periodontists for regular check-ups and prophylactic treatments which, will reduce the chances of oral infections and further chances of adverse pregnancy outcomes.
CONCLUSIONS
The present study shows that there is a significant correlation between periodontal disease and adverse pregnancy outcomes in the Qassim population. In addition, there is need for awareness and timely preventive intervention in reducing the periodontal inflammation among expectant mothers. Further, to substantiate our results, larger population prospective studies are essential which will help authorities institute a policy for preventive dental programs for the masses.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Acknowledgment
We would like to thank the Maternal and Children's Hospital for their support in conducting our study. We also grateful to the Gynecology and Obstetrics Department MCH for providing good work environment.
REFERENCES
- 1.Armitage GC. Periodontal diagnoses and classification of periodontal diseases. Periodontol. 2000;2004(34):9–21. doi: 10.1046/j.0906-6713.2002.003421.x. [DOI] [PubMed] [Google Scholar]
- 2.Costa F, Oliveira A, Cota L. Interrelation between periodontal disease and preterm birth. 2013 [Google Scholar]
- 3.Hassan KS, Alagl AS, El-Tantawy M, Alnimr AM, Haseeb YA. The prevalence and association of preterm birth with periodontal disease in the eastern province of Saudi Arabia: Microbiological and immunochemistry evaluations. OHDM. 2015;14:7. [Google Scholar]
- 4.Ide M, Papapanou PN. Epidemiology of association between maternal periodontal disease and adverse pregnancy outcomes – systematic review. J Periodontol. 2013;84:S181–94. doi: 10.1902/jop.2013.134009. [DOI] [PubMed] [Google Scholar]
- 5.Sanz M, Kornman K. Periodontitis and adverse pregnancy outcomes: Consensus report of the Joint EFP/AAP workshop on periodontitis and systemic diseases. J Periodontol. 2013;84:S164–9. doi: 10.1902/jop.2013.1340016. [DOI] [PubMed] [Google Scholar]
- 6.The worldwide incidence of low birth-weight: An update. Bull Pan Am Health Organ. 1984;18:300–1. [PubMed] [Google Scholar]
- 7.Lisbeth B. Knudsen. Birth Counts. Statistics of Pregnancy and Childbirth. (2nd ed) 2002;1& 2:447–673. [Google Scholar]
- 8.Xiong X, Buekens P, Goldenberg RL, Offenbacher S, Qian X. Optimal timing of periodontal disease treatment for prevention of adverse pregnancy outcomes: Before or during pregnancy? Am J Obstet Gynecol. 2011;205:111.e1–6. doi: 10.1016/j.ajog.2011.03.017. [DOI] [PubMed] [Google Scholar]
- 9.Penova-Veselinovic B, Keelan JA, Wang CA, Newnham JP, Pennell CE. Changes in inflammatory mediators in gingival crevicular fluid following periodontal disease treatment in pregnancy: Relationship to adverse pregnancy outcome. J Reprod Immunol. 2015;112:1–10. doi: 10.1016/j.jri.2015.05.002. [DOI] [PubMed] [Google Scholar]
- 10.Offenbacher S, Lin D, Strauss R, McKaig R, Irving J, Barros SP, et al. Effects of periodontal therapy during pregnancy on periodontal status, biologic parameters, and pregnancy outcomes: A pilot study. J Periodontol. 2006;77:2011–24. doi: 10.1902/jop.2006.060047. [DOI] [PubMed] [Google Scholar]
- 11.Al-Qurashi FO, Yousef AA, Awary BH. Epidemiological aspects of prematurity in the Eastern region of Saudi Arabia. Saudi Med J. 2016;37:414–9. doi: 10.15537/smj.2016.4.14309. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Abolfotouh MA, Al Saif S, Altwaijri WA, Al Rowaily MA. Prospective study of early and late outcomes of extremely low birthweight in Central Saudi Arabia. BMC Pediatr. 2018;18:280. doi: 10.1186/s12887-018-1248-y. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Al Hazzani F, Al-Alaiyan S, Hassanein J, Khadawardi E. Short-term outcome of very low-birth-weight infants in a tertiary care hospital in Saudi Arabia. Ann Saudi Med. 2011;31:581–5. doi: 10.4103/0256-4947.87093. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Al-Turki HA. A review of 33 years (1980-2013) of data indicating a rise in ectopic pregnancy in Saudi Arabia. Int J Gynaecol Obstet. 2015;128:33–5. doi: 10.1016/j.ijgo.2014.07.037. [DOI] [PubMed] [Google Scholar]
- 15.Wardlaw T, editor. Weltgesundheitsorganisation. Low birthweight: Country, regional and global estimates. Geneva: 2004. p. 27. [Google Scholar]
- 16.Tshotetsi L, Dzikiti L, Hajison P, Feresu S. Maternal factors contributing to low birth weight deliveries in Tshwane District, South Africa. PLoS One. 2019;14:e0213058. doi: 10.1371/journal.pone.0213058. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Hassan AA, Abubaker MS, Radi EA, Adam I. Education, prenatal care, and poor perinatal outcome in Khartoum, Sudan. Int J Gynaecol Obstet. 2009;105:66–7. doi: 10.1016/j.ijgo.2008.10.026. [DOI] [PubMed] [Google Scholar]
- 18.Silness J, Loe H. Periodontal disease in pregnancy. II. Correlation between oral hygiene and periodontal condtion. Acta Odontol Scand. 1964;22:121–35. doi: 10.3109/00016356408993968. [DOI] [PubMed] [Google Scholar]
- 19.Ramfjord SP. Indices for prevalence and incidence of periodontal disease. J Periodontol. 1959;30:51–9. [Google Scholar]
- 20.Khader Y, Al-shishani L, Obeidat B, Khassawneh M, Burgan S, Amarin ZO, et al. Maternal periodontal status and preterm low birth weight delivery: A case-control study. Arch Gynecol Obstet. 2009;279:165–9. doi: 10.1007/s00404-008-0696-2. [DOI] [PubMed] [Google Scholar]
- 21.Daalderop LA, Wieland BV, Tomsin K, Reyes L, Kramer BW, Vanterpool SF, et al. Periodontal disease and pregnancy outcomes: Overview of systematic reviews. JDR Clin Trans Res. 2018;3:10–27. doi: 10.1177/2380084417731097. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Cobb CM, Kelly PJ, Williams KB, Babbar S, Angolkar M, Derman RJ. The oral microbiome and adverse pregnancy outcomes. Int J Womens Health. 2017;9:551–9. doi: 10.2147/IJWH.S142730. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Mobeen N, Jehan I, Banday N, Moore J, McClure EM, Pasha O, et al. Periodontal disease and adverse birth outcomes: A study from Pakistan. Am J Obstet Gynecol. 2008;198:514.e1–8. doi: 10.1016/j.ajog.2008.03.010. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Vettore MV, Leão AT, Leal Mdo C, Feres M, Sheiham A. The relationship between periodontal disease and preterm low birthweight: Clinical and microbiological results. J Periodontal Res. 2008;43:615–26. doi: 10.1111/j.1600-0765.2007.01027.x. [DOI] [PubMed] [Google Scholar]
- 25.Pitiphat W, Joshipura KJ, Gillman MW, Williams PL, Douglass CW, Rich-Edwards JW. Maternal periodontitis and adverse pregnancy outcomes. Community Dent Oral Epidemiol. 2008;36:3–11. doi: 10.1111/j.1600-0528.2006.00363.x. [DOI] [PubMed] [Google Scholar]
- 26.Samant A, Malik CP, Chabra SK, Devi PK. Gingivitis and periodontal disease in pregnancy. J Periodontol. 1976;47:415–8. doi: 10.1902/jop.1976.47.7.415. [DOI] [PubMed] [Google Scholar]
- 27.Heimonen A, Janket SJ, Kaaja R, Ackerson LK, Muthukrishnan P, Meurman JH. Oral inflammatory burden and preterm birth. J Periodontol. 2009;80:884–91. doi: 10.1902/jop.2009.080560. [DOI] [PubMed] [Google Scholar]
- 28.Gomes-Filho IS, Cruz SS, Rezende EJ, Dos Santos CA, Soledade KR, Magalhães MA, et al. Exposure measurement in the association between periodontal disease and prematurity/low birth weight. J Clin Periodontol. 2007;34:957–63. doi: 10.1111/j.1600-051X.2007.01141.x. [DOI] [PubMed] [Google Scholar]
- 29.Mitchell-Lewis D, Engebretson SP, Chen J, Lamster IB, Papapanou PN. Periodontal infections and pre-term birth: Early findings from a cohort of young minority women in New York. Eur J Oral Sci. 2001;109:34–9. doi: 10.1034/j.1600-0722.2001.00966.x. [DOI] [PubMed] [Google Scholar]
- 30.Davenport ES, Williams CE, Sterne JA, Murad S, Sivapathasundram V, Curtis MA. Maternal periodontal disease and preterm low birthweight: Case-control study. J Dent Res. 2002;81:313–8. doi: 10.1177/154405910208100505. [DOI] [PubMed] [Google Scholar]
- 31.Konopka T, Rutkowska M, Hirnle L, Kopec W, Karolewska E. The secretion of prostaglandin E2 and interleukin 1-beta in women with periodontal diseases and preterm low-birth-weight. Bull Group Int Rech Sci Stomatol Odontol. 2003;45:18–28. [PubMed] [Google Scholar]
- 32.Mokeem SA, Molla GN, Al-Jewair TS. The prevalence and relationship between periodontal disease and pre-term low birth weight infants at King Khalid University Hospital in Riyadh, Saudi Arabia. J Contemp Dent Pract. 2004;5:40–56. [PubMed] [Google Scholar]
- 33.Offenbacher S, Katz V, Fertik G, Collins J, Boyd D, Maynor G, et al. Periodontal infection as a possible risk factor for preterm low birth weight. J Periodontol. 1996;67:1103–13. doi: 10.1902/jop.1996.67.10s.1103. [DOI] [PubMed] [Google Scholar]
- 34.Jeffcoat MK, Geurs NC, Reddy MS, Cliver SP, Goldenberg RL, Hauth JC. Periodontal infection and preterm birth: Results of a prospective study. J Am Dent Assoc. 2001;132:875–80. doi: 10.14219/jada.archive.2001.0299. [DOI] [PubMed] [Google Scholar]
- 35.Glotov AS, Tiys ES, Vashukova ES, Pakin VS, Demenkov PS, Saik OV, et al. Molecular association of pathogenetic contributors to pre-eclampsia (pre-eclampsia associome) BMC Syst Biol. 2015;9(Suppl 2):S4. doi: 10.1186/1752-0509-9-S2-S4. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 36.Gogeneni H, Buduneli N, Ceyhan-Öztürk B, Gümüş P, Akcali A, Zeller I, et al. Increased infection with key periodontal pathogens during gestational diabetes mellitus. J Clin Periodontol. 2015;42:506–12. doi: 10.1111/jcpe.12418. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 37.Sharma A, Ramesh A, Thomas B. Evaluation of plasma C-reactive protein levels in pregnant women with and without periodontal disease: A comparative study. J Indian Soc Periodontol. 2009;13:145–9. doi: 10.4103/0972-124X.60227. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 38.Jiang H, Xiong X, Su Y, Peng J, Zhu X, Wang J, et al. Use of antiseptic mouthrinse during pregnancy and pregnancy outcomes: A randomised controlled clinical trial in rural China1. BJOG Int J Obstet Gynaecol. 2016 Sep;123(Suppl 3):39–47. doi: 10.1111/1471-0528.14010. [DOI] [PubMed] [Google Scholar]
- 39.Guidelines on perinatal oral health care. Am Academy Pediatric Dent. 2010;32:109–13. [Google Scholar]
- 40.Saini R, Saini S, Saini SR. Periodontitis: A risk for delivery of premature labor and low-birth-weight infants. J Nat Sci Biol Med. 2010;1:40–2. doi: 10.4103/0976-9668.71672. [DOI] [PMC free article] [PubMed] [Google Scholar]