Saving Lives at Birth: Primary Prevention of Periodontal Disease in Relation to Preterm Birth in Malawi

Not Applicable

Completed

• Conditions: Preterm Birth; Periodontal Disease; Caries, Dental
• Interventions: Dietary Supplement: Xylitol gum

• Registration Number: NCT02333227
• Lead Sponsor: Baylor College of Medicine

Brief Summary

The hypothesis of the investigators' project is that comprehensive primary preterm birth prevention, inclusive of maternal oral health with xylitol chewing gum (the intervention), will reduce the rate of periodontal disease and caries, preterm birth prevalence, and neonatal mortality.

Detailed Description

Significance and Impact: Adverse birth outcomes related to the length of gestation (preterm birth) are recognized as one of the most significant disorders in maternal-child health at a global scale. In the developed world, the preterm birth rate approximates 7%. In Malawi, the investigators have recently demonstrated that this rate more than triples to approximate 26.1%. Of the 4 million newborn deaths annually, nearly 1/3 (27%) are directly attributable to prematurity with another 36% secondary to related opportunistic infections (sepsis, pneumonia, gastrointestinal). 75% of the 4 million deaths occur within the first week of life, with the vast majority occurring in the first 48 hours. For those that do survive, there are persistent and lifelong risks due to stunted growth, chronic infection, retinopathy of prematurity, and bronchopulmonary dysplasia. The link between maternal oral health (periodontal disease in particular) and risk of preterm birth has been demonstrated across all populations (rural and urban, in both industrialized and developing regions) studied to date. However, in multiple randomized controlled trials treatment of active periodontal disease with scaling and planning during pregnancy has failed to demonstrate a significant benefit in preventing preterm birth.

Why would maternal oral health impact preterm birth? In rodents, subcutaneous inoculations with periodontal pathogens cause dose-dependent decreases in pup weights, and elicit inflammatory responses that can trigger preterm birth when present in amniotic fluid. Periodontitis (defined as a destructive inflammation of the periodontium) has a prevalence of 30% or greater in women of child bearing age. By definition, it involves microbial infiltration of the periodontium, which stimulates a chronic inflammatory response, recurrent bacteremia, and the production of cytokines and prostaglandins which trigger risk of preterm birth. It is the same production of prostaglandins which are felt to mediate the risk of preterm birth. So if the investigators know that there is biologic evidence that periodontitis is related to preterm birth, but treating active periodontitis does not reduce these morbidities, is it possible that preventing periodontitis might prevent preterm birth and low birth weight? If so, what are the least expensive efficacious preventative measures? The investigators' overarching hypothesis is that comprehensive primary preterm birth prevention, inclusive of maternal oral health with xylitol chewing gum (the intervention), will reduce the rate of periodontal disease and caries, preterm birth prevalence, and neonatal mortality.

Basic Information
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Recruitment & Eligibility
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Study & Design
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Trial Locations

Study Timeline

• Study First Submitted: 2014-12-23
• Study First Submitted QC: 2015-01-06
• Study First Posted: 2015-01-07
• Study Start: 2015-05-01
• Primary Completion: 2021-10-31
• Study Completion: 2021-12-01
• Results First Submitted: 2022-03-15
• Status Verified: 2023-03
• Results First Submitted QC: 2023-03-22
• Last Update Submitted: 2023-03-22
• Results First Posted: 2024-01-08
• Last Update Posted: 2024-01-08

Recruitment & Eligibility

• Status: COMPLETED
• Sex: Female
• Target Recruitment: 10069

Inclusion Criteria

1. Enrollment at <20 weeks gestation by best obstetrical estimate, or
2. Enrollment post partum with an anticipated next pregnancy within 18 months, or
3. Enrollment preconception with an anticipated pregnancy within 18 months (preconception); and
4. Cognitively aware enough to participate in the study
5. >18 years of age (in Malawi, constitutes a legal adult and capacity to consent for study)
6. Willing to participate in the study
7. Willing to undergo at least two periodontal exams
8. Willing to chew 1 piece of xylitol gum for 10 minutes after the morning and evening meal (intervention sites)
9. Anticipating to remain within the region for 18 months

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Exclusion Criteria

1. >20 weeks gestation by best obstetrical estimate
2. Post partum and not anticipating another pregnancy within 18 months
3. Preconception and not anticipating another pregnancy within 18 months
4. Not cognitively aware enough to participate in the study
5. Not willing to undergo at least two periodontal exams
6. <18 years of age
7. Not willing to chew 1 piece of xylitol gum for 10 minutes after the morning and evening meal (intervention sites)
8. Anticipating a move outside of the region within 18 months

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Study & Design

• Study Type: INTERVENTIONAL
• Study Design: PARALLEL

Arm && Interventions

Group	Intervention	Description
Xylitol	Xylitol gum	Cluster of sites receiving xylitol gum.

Primary Outcome Measures

Name	Time	Method
Rate of Preterm Birth	Conception to date of delivery, <37 weeks gestation	This is a co-primary outcome: Measure rate of preterm birth \<37 weeks gestation, as defined by best obstetrical estimate based upon last menstrual period correlated with fundal height at entry to prenatal care or ultrasound, when available; all sites have access to referral for ultrasound.
Number of Infants <2500 Grams	Date of delivery to 1 week postnatal	This is a co-primary outcome: Measured weight at delivery to determine the rate of \<2500 gram infants.

Secondary Outcome Measures

Name	Time	Method
Number of Participants With Periodontal Disease	During pregnancy, up to 2 dental visits performed during pregnancy (approximately 37-40 weeks if term) to evaluate dental outcomes	We will measure the prevalence of periodontal disease among gravidae. We will use standardized World Health Organization (WHO) oral health forms and disease scoring.
Number of Infants With Adverse Neonatal Composite Morbidity and Mortality	Date of delivery to 28 days postnatal	Additive or singular composite neonatal morbidity up to 28 days of age. Composite neonatal morbidity and mortality outcomes are defined as: neonatal death, miscarriage \<28 weeks, stillbirth (fresh or macerated), neonatal sepsis, neonatal respiratory distress, neonatal seizures, feeding problems, fever, hypothermia, Apgar score \<7 at 5 minutes after birth, referral to other hospital or neonatal intensive care unit (NICU)
Number of Participants With Dental Caries	During pregnancy, up to 2 dental visits performed during pregnancy (approximately 37-40 weeks if term) to evaluate dental outcomes	We will measure the prevalence of dental caries among gravidae. We will use standardized World Health Organization (WHO) oral health forms and disease scoring.

Trial Locations

Locations (1)

Baylor College of Medicine; 🇺🇸 Houston, Texas, United States