mental health disorders, including schizophrenia, bipolarand unipolar disorders, puerperal disorders, and all dis-orders combined.

Both outpatient contacts and hospitalizations for allmental health disorders were highest in primiparas whencompared with non-mothers and other postpartumwomen beyond their first year or with a second or thirdchild. While risk remains high for postpartum primiparaswithin the first year, it is highest 10 to 19 days followingdelivery. The state of being pregnant appeared to exert aprotective effect against hospitalization or outpatientcontact for mental health disorders in women. Therewere no significant mental health disorders noted forfirst-time fathers in the first year following birth of achild (when compared with similar men who were notfathers), though other studies have suggested otherwise.

In the accompanying editorial, Wisner et al. point outthat PPD is more common than is appreciated and verylittle about it has been studied since the EdinburghDepression Scale was published in 1987—20 years ago!Given the new information presented in this study,clinicians can identify risk factors for PPD and considerscreening primiparas earlier than the standard 6-weekcheck-up and again later in the first year (at 3 months).More formal screening can take place and be documentedin the record. The Edinburgh Depression Scale is a brief10-item questionnaire, has been proven valid, and couldbe more widely applied in practice. Treatment for PPD ismore successful when started early in the illness process.

TREATMENT OF PERIODONTAL DISEASE IN PREGNANCYDOES NOT AFFECT RATES OF PREMATURITY, LOW BIRTHWEIGHT, OR INTRAUTERINE GROWTH RESTRICTIONMichalowicz BS, Hodges JS, DiAngelis AJ, Lupo VR, Novak MJ,Ferguson JE, et al. Treatment of periodontal disease and the riskof preterm birth. N Engl J Med 2006;355:1885–94.

Reviewed by: Sharon Bond, CNM, APRN-BC.

Dental disease has been linked with poor pregnancyoutcomes, such as premature labor, low birth weight,intrauterine growth restriction, and pre-eclampsia,though causation has not been established. It has beenhypothesized that gram-negative bacteria which causeperiodontitis and damage bone and connective tissuesthat support teeth also cause an inflammatory process

that may have systemic health implications. This hasbeen theorized to occur when bacteria invade the placenta,membranes, and amniotic fluid, leading to preterm labor.

This is a blinded, randomized, controlled trial whichoccurred in four medical centers involving 823 pregnantwomen. Following consent, all received screening forperiodontal disease and, if present, were randomly as-signed to a treatment or control group. The treatmentgroup (N � 413) received non-surgical care for theirdisease, which included plaque and calculus removal andinstruction in oral hygiene. The control group (N � 410)received the same number of visits, but their periodontaltreatment was delayed until after delivery. All providersreceived training from the same clinician (Michalowicz)so that periodontal care would be delivered to subjects inthe same way. Women were then compared for length ofgestational age, birth weight, and whether their infantswere small for gestational age.

Outcomes for gestational age and birth weight weresimilar and there were no significant differences betweenthe control and treatment groups. There were no measur-able differences within the treatment groups among thefour participating medical centers. Follow-up rates werefairly high. When authors looked at outcomes only forwomen having the most severe periodontal disease, therewere no differences. Because these findings differ fromthose of earlier studies, the authors considered severalpossible reasons for the discrepancies. For example, perhapsthe treatment did not affect the disease process enough toalter birth outcomes. Other studies used antibiotics in theirtreatment groups, or perhaps periodontal disease needs to betreated before (rather than during) pregnancy in order tomeasure differences.

Many midwives work in settings where women havelimited access to dental services. Some women have neverconsulted a dentist or hygienist. As health care profession-als, it is our understanding that good dental hygiene and theabsence of disease is beneficial in helping women maintaina healthy pregnancy. This study suggests that treatment ofperiodontal disease during pregnancy is safe and improvesperiodontal disease, but does not affect pregnancy out-come. If not to prevent premature births, midwives cancontinue to refer women noted to have poor oral hygieneto dental providers for evaluation and treatment.

Journal of Midwifery & Women’s Health • www.jmwh.org 311