European Journal of Cardiovascular Medicine

Periodontal disease is a chronic inflammatory condition of the supporting structures of the teeth, primarily caused by pathogenic bacterial biofilms and modified by host immune responses. It is characterized by gingival inflammation, loss of connective tissue attachment, and alveolar bone destruction, leading ultimately to tooth mobility and loss if left untreated.^1,2 Over the past few decades, periodontal disease has been increasingly recognized not merely as an oral health problem, but as a condition with potential systemic implications. Chronic inflammation and bacteremia associated with periodontitis may act as a reservoir of inflammatory mediators and pathogenic organisms, influencing systemic health and disease processes beyond the oral cavity.³

Pregnancy is a unique physiological state associated with complex hormonal, immunological, and vascular changes that affect multiple systems, including the periodontium. Elevated levels of estrogen and progesterone during pregnancy can exacerbate gingival inflammation and vascular permeability, predisposing women to pregnancy-associated gingivitis and progression of periodontal disease.⁴ While these changes are often considered reversible postpartum, in certain women they may contribute to clinically significant periodontal breakdown. In recent years, a growing body of literature has explored the possible link between periodontal disease and adverse pregnancy outcomes. Epidemiological studies suggest that periodontitis may be associated with preterm birth, low birth weight, preeclampsia, and intrauterine growth restriction.^5-9 The proposed biological mechanisms include systemic dissemination of periodontal pathogens and their endotoxins, as well as elevated maternal levels of pro-inflammatory cytokines such as tumor necrosis factor-alpha (TNF-α), interleukin-1 (IL-1), and prostaglandin E2, which may induce uterine contractions or impair placental function. This aligns with the broader “fetal origins” hypothesis, which emphasizes maternal inflammatory and infectious exposures as important determinants of perinatal outcomes. However, the evidence linking periodontal disease and pregnancy outcomes remains inconsistent. While several studies and meta-analyses report significant associations, others have found no conclusive evidence of a causal relationship, particularly when confounding variables such as socioeconomic status, smoking, maternal nutrition, and access to prenatal care are considered.^10--12 These discrepancies highlight the complexity of disentangling the independent effect of periodontal disease from other risk factors. Importantly, most studies have focused on high-risk pregnant women, leaving a relative paucity of data regarding low-risk populations who may not have traditional obstetric risk factors but still could experience adverse outcomes linked to periodontal health. Evaluating this association in low-risk pregnant women is particularly important, as it allows for evaluation of periodontal disease as an independent contributor to pregnancy outcomes, minimizing confounding effects from established high-risk conditions.

This perspective not only enhances our understanding of the oral-systemic connection but also underscores the potential role of oral health interventions in prenatal care. If a causal relationship is established, periodontal screening and management could represent a cost-effective, non-invasive strategy to improve maternal and neonatal outcomes. Therefore, this study aims to evaluate the association between periodontal disease and pregnancy outcomes in low-risk pregnant women. By focusing on this population, the research seeks to clarify whether periodontal health independently contributes to perinatal outcomes and to provide evidence that may guide future preventive and therapeutic approaches within obstetric and dental practice.

The present prospective observational study was conducted in Department of Oral and Maxillofacial Surgery, Desh Bhagat Dental College, over a period of one year with effect from May 2024 to April 2025.  The study aimed to evaluate the association between periodontal disease and pregnancy outcomes in low-risk pregnant women.

All pregnant women attending the antenatal clinic or admitted for delivery during the study period were screened for eligibility. Only low-risk pregnant women were included, defined as those without any significant systemic illness or obstetric complications such as preeclampsia, gestational diabetes mellitus, chronic hypertension, thyroid disease, multiple pregnancies, or a history of recurrent pregnancy loss. Women with high-risk factors, those with systemic infections, those on long-term medications affecting periodontal status (e.g., corticosteroids, immunosuppressants, anticonvulsants), and women who had undergone periodontal treatment during pregnancy were excluded from the study.

A total of 78 pregnant women fulfilling the inclusion criteria were enrolled after obtaining informed consent. The participants were divided into two groups based on their periodontal status at the time of assessment:

• Cases (n = 37): Pregnant women diagnosed with periodontitis.
• Controls (n = 41): Pregnant women without periodontitis.

A structured proforma was used to record demographic and obstetric details such as age, gravida, gestational age at delivery, and neonatal outcomes. Detailed oral examinations were carried out in collaboration with the Department of Dentistry to assess periodontal health. The periodontal parameters assessed in this study included the plaque index, used to measure plaque accumulation; the gingival index, which evaluated the degree of gingival inflammation; and bleeding on probing, considered an indicator of gingival bleeding and periodontal inflammation. Periodontitis was diagnosed based on the presence of gingival inflammation, periodontal pocket depth ≥4 mm, clinical attachment loss, and bleeding on probing at multiple sites, in accordance with the CDC-AAP case definition. Pregnancy outcomes were recorded at delivery and included:

• Gestational age at delivery, categorized as <37 weeks (preterm) or ≥37 weeks (term).
• Birth weight of the neonate, categorized as <2.5 kg (low birth weight) or ≥2.5 kg (normal birth weight).

Statistical Methods:

The recorded data was compiled and entered in a spreadsheet (Microsoft Excel) and then exported to data editor of SPSS Version 20.0 (SPSS Inc., Chicago, Illinois, USA). Continuous variables were expressed as Mean±SD and categorical variables were summarized as frequencies and percentages. The Shapiro-Wilk test was applied to test the normality of data. Student’s independent t-test or Mann-Whitney U-test, whichever feasible, was employed for comparing continuous variables. Chi-square test or Fisher’s exact test, whichever appropriate, was applied for comparing categorical variables. A P-value of less than 0.05 was considered statistically significant. 

The present prospective observational study was conducted in Department of Oral and Maxillofacial Surgery, Desh Bhagat Dental College, over a period of one year with effect from May 2024 to April 2025.  The study aimed to evaluate the association between periodontal disease and pregnancy outcomes in low-risk pregnant women.

All pregnant women attending the antenatal clinic or admitted for delivery during the study period were screened for eligibility. Only low-risk pregnant women were included, defined as those without any significant systemic illness or obstetric complications such as preeclampsia, gestational diabetes mellitus, chronic hypertension, thyroid disease, multiple pregnancies, or a history of recurrent pregnancy loss. Women with high-risk factors, those with systemic infections, those on long-term medications affecting periodontal status (e.g., corticosteroids, immunosuppressants, anticonvulsants), and women who had undergone periodontal treatment during pregnancy were excluded from the study.

A total of 78 pregnant women fulfilling the inclusion criteria were enrolled after obtaining informed consent. The participants were divided into two groups based on their periodontal status at the time of assessment:

• Cases (n = 37): Pregnant women diagnosed with periodontitis.
• Controls (n = 41): Pregnant women without periodontitis.

A structured proforma was used to record demographic and obstetric details such as age, gravida, gestational age at delivery, and neonatal outcomes. Detailed oral examinations were carried out in collaboration with the Department of Dentistry to assess periodontal health. The periodontal parameters assessed in this study included the plaque index, used to measure plaque accumulation; the gingival index, which evaluated the degree of gingival inflammation; and bleeding on probing, considered an indicator of gingival bleeding and periodontal inflammation. Periodontitis was diagnosed based on the presence of gingival inflammation, periodontal pocket depth ≥4 mm, clinical attachment loss, and bleeding on probing at multiple sites, in accordance with the CDC-AAP case definition. Pregnancy outcomes were recorded at delivery and included:

• Gestational age at delivery, categorized as <37 weeks (preterm) or ≥37 weeks (term).
• Birth weight of the neonate, categorized as <2.5 kg (low birth weight) or ≥2.5 kg (normal birth weight).

Statistical Methods:

The recorded data was compiled and entered in a spreadsheet (Microsoft Excel) and then exported to data editor of SPSS Version 20.0 (SPSS Inc., Chicago, Illinois, USA). Continuous variables were expressed as Mean±SD and categorical variables were summarized as frequencies and percentages. The Shapiro-Wilk test was applied to test the normality of data. Student’s independent t-test or Mann-Whitney U-test, whichever feasible, was employed for comparing continuous variables. Chi-square test or Fisher’s exact test, whichever appropriate, was applied for comparing categorical variables. A P-value of less than 0.05 was considered statistically significant. 

In the present study, out of a total of 78 low-risk pregnant women evaluated, periodontitis was observed in 37 participants, accounting for 47.4% of the study population. The remaining 41 women, constituting 52.6%, did not present with periodontitis. Thus, the incidence of periodontitis in the study cohort was nearly half of the total population.

Table 1 presents the age distribution of cases and controls in the study population. Among the cases, the majority (45.9%) were in the age group of 25–29 years, followed by 37.8% in the 20–24 years group and 16.2% aged 30 years or above. Similarly, in the control group, most participants (43.9%) belonged to the 25–29 years age category, while 31.7% were between 20–24 years and 24.4% were aged 30 years or above. The mean age of cases was 25.9 ± 2.94 years, compared to 26.5 ± 3.71 years in controls. Statistical analysis revealed no significant difference in the age distribution between the two groups (p = 0.435), indicating that cases and controls were well-matched for age.

Table 2 compares the study groups based on gravida status. Among the cases, 48.6% were primigravida and 51.4% were multigravida. Similarly, in the control group, 51.2% were primigravida and 48.8% were multigravida. The distribution of gravida status was therefore nearly equal in both groups. Statistical analysis showed no significant difference between cases and controls (p = 0.821), suggesting that the groups were comparable with respect to parity.

The mean plaque index was significantly higher in cases (1.19 ± 0.417) compared to controls (0.78 ± 0.392), with the difference being statistically significant (p < 0.001). Similarly, the mean gingival index was greater in cases (1.35 ± 0.514) than in controls (0.93 ± 0.418), and this difference also reached statistical significance (p = 0.0002). In addition, bleeding on probing was observed more frequently in cases (1.27 ± 0.375) compared to controls (0.81 ± 0.343), again with a highly significant difference (p < 0.001). These findings indicate that cases exhibited poorer periodontal health compared to controls, as reflected by significantly higher plaque accumulation, gingival inflammation, and bleeding tendency.

Among the cases, a majority (67.6%) delivered before 37 weeks of gestation, whereas only 32.4% delivered at term (≥ 37 weeks). In contrast, among the controls, only 9.8% had preterm deliveries, while the vast majority (90.2%) delivered at term. This difference in gestational age distribution between the two groups was highly significant (p < 0.001), indicating that preterm delivery was considerably more frequent among cases compared to controls.

*Statistically Significant Difference (P-value<0.05)

Table 5 presents the comparison of birth weight between cases and controls. In the case group, a large proportion of neonates (73.0%) had low birth weight (< 2.5 kg), while only 27.0% had a normal birth weight (≥ 2.5 kg). In contrast, among the controls, the majority of neonates (87.8%) had a birth weight of ≥ 2.5 kg, and only 12.2% were of low birth weight. The mean birth weight in cases was 2.28 ± 0.517 kg, which was significantly lower than the mean of 3.17 ± 0.614 kg observed in controls. This difference was highly significant (p < 0.001), suggesting a strong association between case status and reduced birth weight.

In the present study cohort of 78 low-risk pregnant women, nearly half (47.4%) were diagnosed with periodontitis, a substantial prevalence that underscores the considerable oral health burden even among women without traditional obstetric risk factors. This figure aligns closely with findings from a Brazilian investigation, which reported a similar prevalence rate of 47% among low-income, low-risk pregnant women.¹³ Meta-analytic data further support these observations. A systematic review examining periodontal disease during pregnancy estimated a pooled prevalence of approximately 40%, though the reported range was broad extending from 16% up to 67% reflecting diverse diagnostic criteria and population characteristics.¹⁴ Similarly, an observational study found periodontitis affecting 47.1% of pregnant women.¹⁵ These findings suggest that even pregnant women without overt medical or obstetric risk factors can harbor significant periodontal pathology.

In the present study, cases and controls were well matched for age, with the majority of participants belonging to the 25–29 years age group (45.9% of cases and 43.9% of controls), followed by the 20–24 years category (37.8% of cases and 31.7% of controls), while a smaller proportion were aged 30 years or above. The mean age of cases was 25.9 ± 2.94 years, compared to 26.5 ± 3.71 years in controls, with no statistically significant difference between the groups (p = 0.435). This confirms the effectiveness of age matching in our study, thereby reducing the potential confounding influence of age on the observed outcomes. The age distribution observed is consistent with findings from broader epidemiological studies. For instance, an analysis published in PLOS ONE highlighted that the majority of pregnant women diagnosed with periodontal disease fall within the mid-reproductive years, particularly between 25 and 29 years, although an increasing prevalence across older maternal age groups has also been noted. Similarly, Anadure P. et al. reported mean ages of 26.47 ± 3.94 years in the case group and 27.01 ± 3.65 years in the control group, with the difference being statistically insignificant, closely paralleling our findings. Collectively these findings suggest that periodontal disease during pregnancy is most commonly encountered in women within their mid-reproductive years, a period that coincides with peak fertility and the majority of pregnancies. The lack of significant difference in mean age between cases and controls in our study further supports the robustness of the comparative design and strengthens the validity of subsequent analyses by minimizing age as a potential confounder.

In the present study, parity status, categorized as primigravida and multigravida, was comparable between cases (48.6% primigravida and 51.4% multigravida) and controls (51.2% primigravida and 48.8% multigravida), with no statistically significant difference (p = 0.821). This parity matching strengthens the internal validity of the study by minimizing gravidity as a potential confounding factor when assessing the relationship between periodontal disease and pregnancy outcomes. Existing studies provides mixed results into the role of gravidity in periodontal health during pregnancy. Several observational and mechanistic studies have considered pregnancy itself as an exacerbating factor for periodontal disease, largely due to hormonal and immune-mediated changes. However, there is less clarity regarding whether a woman’s gravidity status, defined as the number of prior pregnancies, independently influences her risk of developing periodontal disease in subsequent pregnancies. A  study by Helmi et al., reported no significant relationship between parity and the prevalence of periodontitis among pregnant women, suggesting that previous pregnancies may not exert a cumulative effect on the development or progression of periodontal disease.¹⁷ In contrast, some recent self-reported data indicate that multigravida women tend to report higher levels of periodontal involvement, pointing to a possible association between parity and perceived periodontal health.¹⁸ Conversely, some recent self-reported data indicate that multigravida women may report higher levels of periodontal involvement, pointing to a possible association between parity and perceived periodontal health.¹⁸ This discrepancy may be explained by variations in measurement methods, such as self-reported assessments versus clinical diagnosis, as well as differences in socioeconomic status or hormonal changes associated with repeated pregnancies. These observations highlight the importance of parity matching in the present study, since an uneven distribution of gravidity could introduce bias, particularly if multigravida women are more likely to experience or perceive periodontal concerns.

In our study, periodontal inflammation and plaque accumulation were consistently higher among cases than controls, as evidenced by significantly elevated plaque index (1.19 ± 0.417 vs. 0.78 ± 0.392; p < 0.001), gingival index (1.35 ± 0.514 vs. 0.93 ± 0.418; p = 0.0002), and bleeding on probing (1.27 ± 0.375 vs. 0.81 ± 0.343; p < 0.001). These findings align with reports in low-risk obstetric populations showing higher mean plaque and gingival indices among women with periodontitis compared with periodontally healthy controls; for example, a study by Anadure P et al., on low-risk pregnant women documented significantly greater plaque (≈1.24 vs. 0.84) and gingival indices (≈1.28 vs. 0.91) in cases, with a markedly higher proportion exhibiting gingivitis, paralleling our pattern of results. Likewise, case–control and cohort data from diverse settings have shown that case groups (pregnant women with periodontitis) display significantly worse periodontal parameters including plaque and bleeding indices than controls, reinforcing the biological plausibility that sustained plaque-driven inflammation contributes to adverse outcomes.^19,20 Longitudinal research, including data from the PLOS ONE cohort, has demonstrated that bleeding on probing increases as pregnancy progresses, reflecting heightened gingival inflammation during pregnancy.²¹ This aligns with our observation of elevated bleeding scores, suggesting that pregnancy may exacerbate inflammatory responses in those already predisposed to periodontal disease.

In our cohort, a significant difference in gestational outcomes was observed. Among pregnant women with periodontitis, 67.6% delivered preterm (< 37 weeks), compared to only 9.8% in the control group. Conversely, 90.2% of controls delivered at term, whereas only 32.4% of women with periodontitis reached term gestation. This difference was statistically significant (p < 0.001), strongly suggesting that periodontitis substantially elevates the risk of preterm delivery even in low-risk pregnancies.These findings are in line with a growing body of literature that consistently implicates maternal periodontal disease as a potential risk factor for adverse obstetric outcomes. Offenbacher et al., in a prospective cohort study, reported that women with moderate-to-severe periodontal disease had a significantly higher preterm birth rate (28.6%) compared to those with a healthy periodontium (11.2%).²² Importantly, the association persisted even after adjusting for conventional confounders such as smoking and socioeconomic status, with adjusted relative risks ranging from 1.6 to 2.0. Similarly, Lee et al., in a large population-based cohort study involving over 1.7 million women, demonstrated that the prevalence of preterm birth was higher among those with a history of periodontal disease (11.38%) compared to women without periodontal disease (10.56%).²³ Their study further highlighted a dose-dependent relationship, with adjusted odds ratios increasing with the severity of periodontal disease (OR 1.09 for mild disease and OR 1.13 for advanced disease). Anadure P et al. also reported a significantly higher incidence of preterm delivery, occurring in 63.6% of cases compared to only 7.4% of controls, a finding that closely parallels the results of our study.¹⁶ Supporting these observations, a retrospective case–control study by Uwambaye et al. identified periodontitis as a strong independent predictor of preterm birth, with women affected by periodontal disease showing nearly sixfold higher odds of preterm delivery compared to those without the condition (OR = 6.36; 95% CI 3.9–10.4).²⁴ In nutshell, these studies collectively underscore a consistent and biologically possible link between maternal periodontal disease and preterm birth, further reinforcing the significance of periodontal health in pregnancy outcomes.

In our study, a substantial proportion of neonates born to mothers with periodontitis were of low birth weight (< 2.5 kg), accounting for 73.0% in the case group compared to just 12.2% in controls. Moreover, the mean birth weight was significantly lower in cases (2.28 ± 0.517 kg) than in controls (3.17 ± 0.614 kg; p < 0.001), signaling a strong association between maternal periodontal disease and reduced neonatal birth weight. These findings are well-aligned with a robust body of research. A comprehensive meta-analysis revealed that pregnant women with periodontal disease have a 2.43-fold higher risk of delivering low birth weight infants compared to those with healthy periodontal status.²⁵ Similarly, Corbella et al., in a meta-analysis, reported odds ratios of approximately 1.82 for low birth weight and 3.00 for the combined outcome of preterm and low birth weight, reinforcing the link between periodontal inflammation and fetal growth restriction.²⁶ Further case-control studies echo these observations. In one study, maternal periodontal disease emerged as a significant independent predictor of low birth weight, with odds ratios indicating strong associations.²⁷ Another systematic review emphasized the biological plausibility underpinning this relationship, noting that periodontal pathogens and their inflammatory mediators can negatively influence fetal growth by entering the uteroplacental circulation.²⁸ Anadure P et al., in their study, similarly observed that low birth weight (< 2.5 kg) was present in 69.1% of cases compared to 9.3% of controls, with the difference being statistically significant.¹⁶ This finding closely parallels the results of our study, further reinforcing the association between periodontitis and adverse neonatal outcomes. The convergence of our findings with global evidence underscores the importance of periodontal health in maternal-fetal outcomes.  In nutshell these findings collectively advocate for the integration of periodontal screening and management into prenatal care protocols. 

The present study demonstrated a significant association between maternal periodontal disease and adverse pregnancy outcomes among low-risk pregnant women. While the cases and controls were well matched for age and parity, women with periodontitis consistently demonstrated poorer periodontal health, as reflected by higher levels of plaque accumulation, gingival inflammation, and bleeding on probing. These periodontal disturbances were strongly correlated with unfavorable pregnancy outcomes like an increased risk of preterm delivery and low birth weight. Collectively, the findings of our study suggest the role of maternal oral health as an important determinant of obstetric outcomes and underscore the potential benefits of integrating periodontal evaluation and management into routine antenatal care.

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