Reply to Comment on: Oral health status during pregnancy: rural-urban comparisons of oral disease burden among antenatal women in Sri Lanka

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Dear Editor

We thank Professor Matsubara and co-authors for raising valuable concerns about our recent publication^1,2. They suggest that the four aims of our program may be too many and that it is not determined that oral health care during pregnancy may reduce an adverse pregnancy outcome^2-6. So saying, they refute one of the aims of our national program: 'to reduce the incidence of adverse pregnancy outcomes' stating that recent findings virtually negate its rationale.

Available research findings during the time of preparation of guidelines for incorporation of oral healthcare to the existing National Programme on Maternal and Child Health (MCH)⁷ predominantly suggested a possible association between poor oral health of pregnant women and their pregnancy outcomes, such as low birth weight^8-14. In addition, there are crucial structural and compositional factors in the Sri Lankan public healthcare delivery system against which our context is based. For example, the provision of healthcare to the population of Sri Lanka is predominantly delivered by the state free of charge. Oral health care is closely integrated to the existing public health infrastructure. Hence, it is feasible and cost-effective to incorporate oral health care in the existing National MCH Programme.

Second, the research findings that negate a possible association between oral healthcare provision during pregnancy and pregnancy outcomes have been conducted in western countries like the USA³. Findings clearly indicate a difference in periodontal risk profiles among Sri Lankan pregnant women and US women, the latter having a high prevalence of deep periodontal pockets, the severe form of the disease³.

Third, there are alternative explanations of a lack of association between periodontal care and birth outcomes³. Periodontal disease does increase the risk for preterm birth, but the treatment of this exposure does not reduce the risk because causation and treatment efficacy can be interrelated or the can function independently¹⁵. The classic example in this regard is bacterial vaginosis, which is considered to be one contributing factor in pre-term birth, yet antibiotic treatment of bacterial vaginosis in controlled trials has not reduced the risk of prematurity¹⁶.

We do not support the notion that promoting oral health care is only for oral health. Oral diseases such as dental caries, periodontal disease and oral cancer and many non-communicable diseases, including ischemic heart disease, diabetes mellitus and cancers do share many common preventable/modifiable risk factors including unhealthy dietary patterns, stress and substance abuse. Against this backdrop, the 'common risk factor approach' of oral health promotion practiced in Sri Lanka is mandated by the World Health Organization¹⁷. It is an approach that addresses the risk factors common to many chronic conditions within the wider sociocultural milieu.

In conclusion, the oral health care for pregnant women in Sri Lanka that is integrated to the existing National MCH Programme is influenced by an array of unique contextual and compositional factors in public healthcare delivery system in Sri Lanka. Hence, it is all about thinking globally and acting locally for the benefit of Sri Lankan population.

Nisansala Karunachandra BDS, MSc(CommDent)
Irosha Perera MD(CommDent), Gihan Fernando BDS
Community Dental Unit, Dental Institute
Colombo, Sri Lanka

References

1. Karunachandra NN, Perera IR, Fernando G. Oral health status during pregnancy: rural urban comparisons of oral disease burden among antenatal women in Sri Lanka. Rural and Remote Health 12: 1902. Available: www.rrh.org.au (Accessed 9 July 2012).

2. Matsubara S, Kuwata T, Ohkuchi A. Comment on: oral disease burden among antenatal women in Sri Lanka. Rural and Remote Health 12: 2348. (Online) 2012. Available: www.rrh.org.au (Accessed 25 September 2012).

3. Offenbacher S, Beck JD, Jared HL, Mauriello SM, Mendoza LC, Couper DJ et al. Maternal Oral Therapy to Reduce Obstetric Risk (MOTOR) Investigations: effects of periodontal therapy on rate of pre-term delivery: a randomized controlled trial. Obstetric and Gynecology 2009; 114(3): 1239-1248.

4. Newman JP, Newman IA, Ball CM, Wright M, Panrell CE, Swain J et al. Treatment of periodontal disease during pregnancy: a randomized controlled trial. Obstetric and Gynecology 2009; 114(3): 1239-1248.

5. Boggess KA. Treatment of localized periodontal disease in pregnancy does not reduce the occurrence of preterm birth: results from the Periodontal Infections and Prematurity Study (PIPS). American Journal of Obstetrics and Gynecology 2010; 202(2): 101-102.

6. Macones GA, Parry S, Nelson DB, Strauss JF, Ludmir J, Cohen AW et al. Treatment of localized periodontal disease in pregnancy does not reduce the occurrence of preterm birth: results from the Periodontal Infections and Prematurity Study (PIPS). American Journal of Obstetrics and Gynecology 2010; 202(2): 147.

7. Hill AB. The environment and Disease: association or causation. Proceedings of the Royal Society of Medicine 1965; 58: 295-300.

8. Family Health Bureau, Ministry of Health. Oral health care during pregnancy. Practice Guidelines. Colombo, Sri Lanka: Family Health Bureau, Ministry of Health, 2009.

9. Cruz SS, Costa MCN, Gomes-Filho IS, Rezende EJC, Barreto ML, dos Santos CAST et al. Contribution of periodontal disease in pregnant women as a risk factor for low birth weight. Community Dentistry Oral Epidemiology 2009; 37(6): 527-533.

10. Mobeen N, Jehan I, Banday N, Moore J, Mcclure EM, Pasha O et al. Periodontal disease and adverse birth outcomes: a study from Pakistan. American Journal of Obstetrics and Gynecology 2008; 198(5): 514.e1-8.

11. Siqueira FM, Cota LO, Costa JE, Haddad JP, Lana AM, Costa FO. Intrauterine growth restriction, low birth weight and pre-term birth: adverse pregnancy outcomes and their association with maternal periodontitis. Journal of Periodontology 2007; 78(12): 2266-2276.

12. Toygar HU, Seydaoglu G, Kurklu S, Guzeldemir E, Arpak N. Periodontal health and adverse pregnancy outcomes in 3,576 Turkish women Journal of Periodontology 2007; 78(11): 2081-2094.

13. Xiong X, Buekens P, Vastardis S, Yu SM. Periodontal disease and pregnancy outcomes: state-of-the-science. Obstetrics and Gynecology Survey 2007; 62(9): 605-165.

14. Polyzos NP, Polyzos IP, Mauri D, Tzioras S, Tsappi M, Cortinovis I et al. Effect of periodontal disease treatment during pregnancy on preterm birth incidence: a meta-analysis of randomized trials. American Journal of Obstetrics and Gynecology 2009; 200: 225-232.

15. Stamilio DM, Chang JJ, Macones GA. Periodontal disease and preterm birth: do the data have enough teeth to recommend screening and preventive treatment? American Journal of Obstetrics and Gynecology 2007; 196: 93-94.

16. McDonald H, Brocklehurst P, Parsons J. Antibiotics for treating bacterial vaginosis in pregnancy. Cochrane Database of Systemic Reviews 2005; issue1. Art no: CD000262.DOI:10.1002/14651858.CD000262.pub3.

17. Sheiham A, Watt RG. The common risk factor approach: a rational basis for promoting oral health. Community Dentistry Oral Epidemiology 2000; 28(6): 399-406.