Mechanisms of risk in preterm low-birthweight infants.

The periodontal diseases share many common risk factors with preterm low birth weight. Examples are, age, socioeconomic status and smoking (Fig. 5). Studies to date have only shown an association between the two conditions, and this does not indicate a causal relationship. However, since the inflammatory mediators that occur in the periodontal diseases, also play an important part in the initiation of labor, there are plausible biological mechanisms that could link the two conditions. The challenge for the future is to characterize the nature of the factors that predispose a mother to give birth prematurely to infants less than 2500 g and to assign relative probabilities to each. Studies are taking place in many parts of the world to determine the probability of a preterm low-birth-weight outcome, the interdependence of the factors that contribute to a birth event and possible casual relationships between these factors. Further information about the details of the effects of maternal infection will come from intervention studies, animal studies and more detailed examination of the mechanisms.

The East London Study of Maternal Chronic Periodontal Disease and Preterm Low Birth Weight Infants: study design and prevalence data.

The influence of subject-based and environmental factors on the balance between the subgingival microbial challenge and the host response in periodontal diseases illustrates the intimate link between oral and systemic health. From this stems the hypothesis that the persistent Gram-negative challenge and associated inflammatory sequelae in periodontal disease may have consequences extending beyond the periodontal tissues themselves. This paper addresses the design of a case-control study to examine the relationship between preterm low birth weight (PLBW) and maternal periodontal disease. We present preliminary data on the prevalence of these 2 conditions in a group of mothers at the Royal Hospitals Trust, London, U.K. Cases are defined as mothers delivering an infant weighing less than 2,500g before 37 weeks gestation and controls as mothers delivering an infant of more than 2,500g after 38 weeks. We estimated that a study involving 800 mothers (1:3 case:control) should have sufficient power to detect an association with a minimum odds ration of 3 at the 5% significance level. Demographic details of 177 subjects demonstrated that they were representative of the local population, and the prevalence of PLBW was within the expected range. However, the extent and severity of periodontal disease were higher than predicted and may have reflected elevations in gingival inflammation associated with pregnancy. The final outcome of the study should help determine the need for further interventionist studies to demonstrate a causal relationship between periodontal disease and PLBW, as well as provide information on the prevalence of periodontal diseases in this study population.

Environmental causes of enamel defects.

A large number of causes of enamel defects, both environmental and genetic, have been described. However, many of these are derived from case histories and studies of individual conditions. What is needed now is a systematic investigation of the problem. The first requirement in exploring the aetiology further is the standardization of both the clinical diagnosis and the descriptive terminology. This has been provided by the Fédération Dentaire Internationale Developmental Defects of Enamel Index. Comparing studies using standardized methods, including this index, has highlighted areas for closer investigation. The total prevalence of enamel defects in a population needs to be established as a baseline for studies on aetiology. Sixty-eight per cent of 1518 school children in London have enamel defects in the permanent dentition, with 10.5% having 10 or more teeth affected and 14.6% having hypoplasia, i.e. missing enamel. These findings are in contrast to the 37% with hypoplasia found in a group of third to fifth century Romano-Britons from Dorset, England, suggesting further consideration of possible environmental and genetic differences between the two populations. An overall long-term study of dental development in low birth weight children has shown significantly more (P < 0.001) enamel defects related to major health problems during the neonatal period. By using standardized, reproducible criteria in prevalence studies to gain an overview of the problem and then studying specific groups or conditions, it is possible to identify general and specific factors in the aetiology of enamel defects and investigate further the varying role of genetic and environmental effects.

Planning future general anaesthetic services in paediatric dentistry on the basis of evidence: an analysis of children treated in the Day Stay Centre at the Royal Hospitals NHS Trust, London, between 1985-95.

This study aimed to provide evidence for future planning of general anaesthetic services in Paediatric Dentistry. An audit was carried out on children (< or = 17 years) with special needs who were treated under general anaesthesia in the Day Stay Centre at The Royal Hospitals NHS Trust, London, between 1985-95. During these years, 586 child patients were treated, of which 350 had medical complications and/or mental disabilities. Although the number of peri-operative admissions were low (11 planned and 9 emergency), it highlighted the necessity for these patients to be treated in a hospital. Comprehensive dental treatments were carried out which included 1630 deciduous and 596 permanent tooth restorations, and 1382 deciduous and 261 permanent tooth extractions. These patients had follow-up preventive support in the Dental Institute and the readmission rate for further dental treatment under general anaesthesia was low (14 per cent). Comparing the results between 1985-87, 1988-91 and 1992-95 periods, there was a trend for more patients, travelling longer distances, to be treated in the latter periods. It is suggested that more centres with appropriate equipment and trained staff need to be established to meet the increased demand.

Deciduous enamel defects in low-birth-weight children: correlated X-ray microtomographic and backscattered electron imaging study of hypoplasia and hypomineralization.

Enamel does not remodel, and disturbances occurring during development may remain in the tooth as a permanent record of the upset. Mineralization in prenatal and postnatal deciduous enamel was studied in the shed deciduous incisors of low-birth-weight (LBW: < 2kg) children. The specific objective was to gain further insight into the mechanism of formation of developmental defects of enamel. Sections at a resolution of 22-40 microns were reconstructed using X-ray microtomography (microCT) giving absolute measurements of linear absorption coefficient for AgK alpha radiation. Detail to ca. 1 micron resolution was obtained using automated, digital backscattered electron (BSE) imaging of PMMA-embedded material. Matching the histograms of BSE and microCT images made possible the calibration of the mean atomic number-dependent signal in the BSE images. The comparison of abnormal, affected enamel regions and post-recovery, normal, unaffected regions could be made in the same teeth, since these zones were easily recognized from the distribution of hypoplasia and hypomineralization. The microCT values, converted to calculated mineral densities, ranged from 2.3 g cm-3 to 2.6 g cm-3 in LBW hypoplastic, and between 2.65 and 2.78 g cm-3 in control primary enamel and post-defect, post-natal LBW enamel. Hypoplasia with or without minimal hypomineralization indicated recovery of the ameloblasts in the maturation phase. Disturbance during late matrix formation and early maturation resulted in hypoplasia and hypomineralization.

Small primary tooth-crown size in low birthweight children.

As part of a longitudinal study of dental development in a group of low birthweight children (LBW), study models of 72 children at age 7 years were measured to determine the tooth-crown size of primary molars and canines and to compare the findings with equivalent measurements in 60 normal birthweight (NBW) controls. Mesiodistal (length) and buccolingual (width) dimensions were measured manually, using dial calipers. Primary canines and molars were smaller in the LBW than the controls, with significance values ranging from P < 0.001 for the mesiodistal dimension of maxillary and mandibular canine (> 4% difference) to a non-significant difference P < 0.2 for the buccolingual dimension mandibular first primary molar (1.8% difference). Within the LBW group there was a positive correlation between birthweight and mesiodistal tooth size. Small primary tooth size in LBW children may be influenced by both genetic and environmental factors. The shorter prenatal growth period and poor perinatal and early postnatal development may influence the developing deciduous dentition. Small primary tooth-crown size, associated with LBW, should be considered in all population studies of tooth size.

Enamel defects in the primary dentition of children born weighing less than 2000 g.

The findings for enamel defects in the primary dentition of a group of low birthweight (LBW) children were related to their perinatal medical histories. Examination of 110 LBW children and 93 control children aged 5 years showed that significantly more of the LBW children (71%) had hypoplasia than controls (15%), but there was no difference in opacities alone (LBW 25%, control 26%). In the LBW group, defects were seen more often in children classified as ill during the perinatal period, who received ventilator support or intravenous alimentation and in those children born at less than 32 weeks gestation, compared to the LBW children without these perinatal problems. It is speculated that the high incidence and the cause of enamel defects in sick preterm infants may be due to oxygen deprivation and mineral substitute depletion.