Resumen de Association Between Periodontitis and Gestational Diabetes Mellitus: Systematic Review and Meta-Analysis
Rafael Paschoal Esteves Lima, Renata Magalhães Cyrino, Bernardo de Carvalho Dutra, Juliana Oliveira da Silveira, Carolina Castro Martins, Luís Otávio Miranda Cota, Fernando Oliveira Costa
Background: To the best of the authors’ knowledge, there is no systematic review of the potential association between periodontitis and gestational diabetes mellitus (GDM) in the current literature. The aim of the present systematic review and meta-analysis is to search for scientific evidence regarding the association between periodontitis and GDM.
Methods: The present study was conducted in accordance with the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and registered (CRD2014010728) with PROSPERO (International prospective register for systematic reviews, University of York, York, UK). A search was conducted in three electronic databases without restrictions regarding language or date of publication. From 190 studies selected, 15 underwent full-text analysis. Eight studies were eligible (five cross-sectional and three case-control studies), and seven were entered in the meta-analysis. Meta-analysis was performed with tests for sensitivity and statistical heterogeneity. Summary effect measures were calculated by odds ratio (OR) and 95% confidence interval (CI).
Results: There was a significant association between periodontitis and GDM in the meta-analyses of four cross-sectional studies (OR 1.67, 95% CI 1.20 to 2.32) and two case-control studies (OR 2.66, 95% CI 1.52 to 4.65). However, sensitivity tests for case-control studies showed a lack of consistency in data; when including one case-control study, the significance was null (meta-analysis of three case-control studies: OR 1.69, 95% CI 0.68 to 4.21).
Conclusions: There was substantial clinical, methodologic, and statistical heterogeneity among the studies. The scientific evidence cannot affirm a positive association between periodontitis and GDM. Future studies with different designs in distinct populations should be conducted to investigate this association.
Periodontitis is a multifactorial bacterial infection that causes the breakdown of tooth-supporting structures.1 In the past decades, several studies have associated periodontitis with systemic changes.2-6 Gestational diabetes mellitus (GDM) is defined as a condition of glucose intolerance that begins during pregnancy.7 It is a significant cause of maternal and infant morbidity, including macrosomia and maternal hypertensive disorders.8,9 Risk factors for the development of GDM include obesity, previous GDM, maternal age, and family history of diabetes.10,11 Diabetes mellitus has been extensively studied and identified as a risk factor for periodontitis.3,12-16 Changes in the immune-inflammatory response of patients with DM influence the prevalence, severity, and extent of periodontitis.3,17,18 Moreover, periodontitis may have a significant impact on the metabolic condition of DM.19 Periodontitis can contribute to the spread of micro-organisms and bacterial products, inducing a systemic inflammatory process that may initiate and propagate insulin resistance. Inflammatory mediators such as tumor necrosis factor (TNF)-α, interleukin (IL)-6, and C-reactive protein (CRP) may contribute to increased insulin resistance.
It has been suggested that inflammatory and infectious processes may play a role in the pathogenesis of GDM.20 The presence of high levels of CRP, TNF-α, and IL-6 suggest the association of infection and inflammation in the etiology of this hyperglycemia disease.20,21 Observational studies have analyzed a possible association between periodontitis and GDM, but with conflicting findings.22-25 Results of these studies have presented disagreement about this association.
To the best of the authors' knowledge, to date, no systematic review has been undertaken on this important issue. The objective of the present systematic review and meta-analysis is to evaluate the scientific evidence of the association between periodontitis and the development of GDM in pregnant women. If a positive association is determined, treatment of periodontal infection could contribute to reducing morbidity associated with GDM.
