Saturday, June 5, 2010
Thursday, April 22, 2010
Tuesday, April 20, 2010
A large majority of patients with diabetes, the fastest-growing disease in the world, also suffer from oral inflammatory diseases, according to a Canadian study that predicts that the interaction of the two diseases will have a growing impact on both dental and overall healthcare.
"More and more, dental and other healthcare professionals will be required to collaborate to create teams dedicated to the management of people with diabetes at both the community and patient levels, given the interactions between oral inflammation and the comorbidities associated with diabetes," wrote lead study author Anthony Iacopino, D.M.D., Ph.D. (Canadian Journal of Diabetes, September 2009, pp. 146-147).
The authors noted that 75% of diabetics also have gingivitis and periodontitis.
"Yet it also goes without saying that by providing dental care to improve both 'oral' and 'systemic' health, healthcare professionals must remember that 'health is health' and 'disease is disease,' regardless of anatomical location," the authors pointed out.
Don Friedlander, D.D.S., an Ottawa, Ontario, dentist and president of the Canadian Dental Association (CDA), notes that oral health is a component of overall health.
"What we're beginning to understand more and more are the linkages with good general health," he told the Vancouver Sun. "Correlations and associations have been found between poor oral health and many systemic diseases such as cardiovascular disease, diabetes, respiratory problems, and preterm births."
Robert MacGregor, D.D.S., a Nova Scotia dentist and vice president of the CDA, says that in addition to the connection between oral and heart health, "recent research shows that people with oral bacteria and periodontal disease seem more prone to respiratory illness and having babies with low birth weights. And it has long been known that uncontrolled diabetes can lead to aggressive periodontal disease and vice versa," according to the Sun story.
Many chronic inflammatory diseases and conditions have been shown to share common physiological and biochemical bases (especially periodontitis and diabetes), including related underlying pathophysiological mechanisms and risk factors, according to the study authors. "Indeed, the risk factors for cardiovascular disease (a major complication of diabetes) and periodontitis are virtually identical," they wrote.
The researchers noted that diabetes predisposes patients to oral infection, and once the infection is established, it exacerbates diabetes-related hyperglycemia and may even predispose otherwise healthy individuals to develop diabetes.
Patients with diabetes have elevated serum levels of low-density lipoprotein cholesterol and triglycerides (even when blood glucose levels are well-controlled), and these can alter immune cell function via the upregulation of proinflammatory cytokines and downregulation of growth factors, Dr. Iacopino wrote.
This predisposes diabetics to chronic inflammation, progressive tissue breakdown, and diminished tissue repair -- a process that is critically important for periodontal tissues, which are under continual assault by substances emanating from oral biofilms. Hence, periodontitis is more severe and rapidly progressive in people with diabetes compared to people without diabetes, the researchers concluded.
Additionally, periodontitis induces general increases in systemic inflammation and even insulin resistance, along with the potential to destroy pancreatic beta cells. Perhaps this explains why periodontitis has a deleterious effect on diabetes-induced hyperlipidemia, immune cell function, tissue repair, and glucose metabolism, the study authors found.
Studies have shown that when periodontitis is treated, diabetes disease parameters improve.
"All healthcare professionals must recognize that there is no 'trap door' at the mouth," the authors warned. "Oral health is one constituent of general health, existing within the health-disease continuum and requiring attention by all healthcare professionals. Indeed, there is no better model for the concept of interprofessional care than the diabetes-periodontitis axis."
The researchers followed 7,674 patients for a median of 12 years and found that those with fewer teeth were most likely to die, particularly when the death was from cardiovascular disease or coronary heart disease.
The study will be published in the Journal of Periodontology and is available online as the dissertation of Anders Holmlund.
The correlation between death and teeth correlated very highly (p < 0.0001), Holmlund wrote. In fact, those with fewer than 10 teeth were seven times more likely to die during the study than those with more than 25 teeth.
The researchers found correlations among various markers of periodontal disease, such as bleeding on probing and the number of deepened pockets, and hypertension and myocardial infarction, although these were inconsistent.
They also turned up a relationship between antibodies for the periodontal bacterium Porphyromonas gingivalis and myocardial infarction, suggesting a role for this type of infection in both periodontal disease and cardiovascular disease.
Thursday, March 18, 2010
Thursday, March 11, 2010
The objective of this study was to determine the role of Toll-like receptors (TLR) in HIV-1 reactivation induced by periodontal pathogens. The oral Gram-negative but not Gram-positive bacteria enhanced HIV-1LTR activation in BF24 cells. TLR9 activation by F. nucleatum and TLR2 by both Gram-negative bacteria were involved in this response, however TLR4 activation had no effect. Use of NFkB or Sp1 specific chemical inhibitors suggested that these transcription factors are positive and negative regulators of bacterially-induced HIV-1LTR activation, respectively. HIV-1LTR activation and viral replication were similarly induced in THP89GFP cells.
Finally, production of TNFa was enhanced by Gram-negative bacteria and its neutralization reduced HIV-1 reactivation. These results suggest that TLR2 and TLR9 activation by P. gingivalis and F. nucleatum, as well as TNFa produced in response to challenge enhance HIV-1 reactivation in monocytes/macrophages. Increased bacterial growth and emergence of periodontopathogens or their products accompanying chronic oral inflammatory diseases could be risk modifiers for viral replication and transmission, systemic immune activation and AIDS progression in HIV-1 patients.
This is a summary of abstract #927, "TLR2 and TLR9 Activation by Periodontal Pathogens induce HIV-1 Reactivation," to be presented by O.A. Gonzalez at 2 p.m. on Friday, March 5, 2010, in Exhibit Hall D of the Walter E. Washington Convention Center, during the 39th Annual Meeting of the American Association for Dental Research.
Previous studies have explored the effect of periodontal treatment, irrespective of efficacy of treatment, in reducing infant prematurity. In a study titled "Risk of Preterm Birth Is Reduced with Successful Periodontal Treatment," lead researcher M. Jeffcott, and colleagues S. Parry and M. Sammel (all from the University of Pennsylvania, Philadelphia) and G. Macones (Washington University, St. Louis, Missouri) determined whether a reduction in infant prematurity was associated with successful periodontal treatment.
Pregnant subjects between 6 and 20 weeks gestation (using standard pregnancy dating criteria) were eligible for screening and enrollment. Eight hundred and seventy-two subjects with and without periodontal disease were followed. One hundred and sixty subjects with periodontal disease were treated with scaling and root planing. Subjects received periodontal examinations before and after scaling and root planing. Subjects were classified post-hoc according to the results of periodontal treatment: successful treatment ("non-exposure") or unsuccessful treatment ("exposure").
The primary study outcome for this clinical trial was the occurrence of spontaneous preterm birth >periodontal disease had 7.2 percent rate of prematurity less than 35 weeks gestation; subjects with periodontal disease had 23.4 percent rate of prematurity >periodontal disease had a significantly lower incidence of preterm birth less than 35 weeks gestation.
This is a summary of abstract # 690, "Risk of Preterm Birth Is Reduced with Successful Periodontal Treatment," to be presented by M. Jeffcott at 8 a.m. on Friday, March 5, 2010, in room 150A of the Walter E. Washington Convention Center, during the 39th Annual Meeting of the American Association for Dental Research.
Thursday, March 4, 2010
Believe it or not, the answer to the question is quite simple: never! A more scientific way to answer the question is when the laws of physics change! ... which is still never. Despite what we as clinicians hear from salespeople, the laws of physics do not change from one company or product to the next. It is our responsibility as health–care providers to understand the scientific principles of every procedure we perform and the devices we use.
Unfortunately, the first place many dentists look for knowledge and advice should be the last, namely the salesperson. Their primary objective and responsibility is to sell us their products, not to educate or advise us on the laws of physics or how to provide quality health care. The proper place to gain knowledge and learn the science of health care is in scientific literature and academic environments, such as the ALD or AGD. The primary goal of these organizations is to be the profession’s source for information and education on the true science and clinical applications in a noncommercial, unbiased manner. This is especially true when it comes to properly understanding use of light–based technologies, particularly lasers in dentistry.
The promotion, popularity, and successful outcomes of laser treatment in other areas of health care, such as ophthalmology, plastic surgery, and dermatology, have made patients more inquisitive about the use of lasers in dentistry. This desire facilitates the investigation and use of lasers in all aspects of dentistry by patients and clinicians alike.
Almost everyone believes that laser therapy should reduce the concerns and improve outcomes over conventional dental treatment. This especially holds true for periodontal and soft tissue therapy, which covers the full range of applications from preventive to the most advanced surgical procedures as shown in Table 1. Look at Table 2 for some considerations when selecting a laser.
The mechanism of laser surgery works like this: As the laser precisely cuts or “vaporizes” soft tissue, which is called ablation, it coagulates the tissue. This controlled coagulation increases hemostasis and is almost bloodless in many cases. This hemostatic control combines with the bactericidal effect of the laser energy at the surgical site, reduces the discomfort during treatment, and minimizes the risk of infections and the need for antibiotics and sutures.
It also minimizes the inflammatory response, allowing faster and improved healing with less postoperative discomfort. This control also means that when the correct laser with the proper parameters is used for the appropriate procedure, it is often faster and more efficient.
The ability to control hemostasis allows the routine performance of both hard tissue procedures such as subgingival Class V restorations and digital impressions to be completed in the same appointment, which includes the needed gingival recontouring or troughing and the definitive restoration. The ability to combine procedures makes it more convenient for patients because fewer appointments are required and the practice’s efficiency and profitability are increased.
It is commonly known that if oral cancer is diagnosed and treated in its earliest stages, the success rate is higher. When the proper laser and techniques are used to control the collateral thermal damage, there is minimal heat artifact in the biopsy specimen. This enables the general practitioner to quickly and easily perform a biopsy with a laser when first deemed appropriate, causing minimal bleeding and discomfort to the patient during the procedure and postoperatively. Hopefully early detection will become more common.
When evaluating which laser is best for your practice, the most important considerations are: who is going to use it, what procedures it is going to perform, why it is going to be beneficial, where it is going to be placed, and how the device–specific training is going to be done.
This simple who, what, why, where, when, and how philosophy may seem very elementary, but it is all too often overlooked when a practice incorporates new technology. In laser dentistry, this also translates into investigating the science of laser physics, the ergonomics and portability of the device, the type of training included, the cost, and the dependability of the manufacturer.
How the laser interacts with tissue is strictly dependent on the laser physics. The science does not change from device to device, but the individual properties of each device do. Today, almost all dental lasers have the ability to perform soft tissue procedures with varying efficiency, depending on the wavelength of the laser energy and the ability to control that energy’s interaction with the tissue.
The benefit of laser use for soft tissue treatment and management is that the treatments are often less invasive, more precise, and very conservative, preserving the healthy tissue while treating the diseased site. These benefits greatly reduce discomfort during treatment and minimize the need for local anesthesia for many procedures.
The tissue reacts predictably with less shrinkage and with minimal inflammatory response, reducing the postoperative discomfort that has been attributed to many of these therapies. Basically, it is “what you see is what you get” treatment in the majority of cases. Soft tissue laser treatment can reduce the need for outside referrals and additional appointments, thus increasing comfort and convenience for patients and still providing state–of–the–art clinical care with minimally invasive procedures.
The ability of laser light energy to ablate (vaporize or cut) tissue is dependent on how well the energy is absorbed by that tissue, the amount of energy or power (watts), and the amount of time the energy is being emitted into the tissue. The key to achieving the maximum efficiency for this tissue interaction is to match these variables with the chromophores (absorbers of light) present in the tissue with a laser that emits the proper wavelength.
The chromophores found in oral soft tissue are water, hemoglobin, oxyhemoglobin, and melanin. With oral soft tissue being comprised of approximately 70% water, it is the primary chromophore that the laser should be targeting. A study by Cecchetti et al., demonstrated that when comparing light energies in the near infrared range, the 980 nm (nanometer) wavelength used by a few diode lasers is absorbed more than 10 times greater than the 810 nm wavelength that is used by most diode lasers, and three times more than the 1,064 nm of the Nd:YAG lasers. Mid infrared range erbium lasers with 2,790 nm to 2,940 nm wavelengths and 10,600 nm, and the far infrared CO2 lasers have significantly higher absorption in water than those in the near infrared range.
To compensate for the lack of light energy absorption of the 810 nm class of lasers, the fiber tip is initiated by blocking the light energy with the ink of an articulating paper or the carbon of a cork. This fiber tip essentially becomes a hot glass rod that vaporizes the tissue by conduction heat transferred by direct contact of the fiber with tissue.
The free running 1,064 nm Nd:YAG laser compensates for its lack of absorption by using an extremely high peak power of as much as 1,000 watts of power for a very short interval, so the average power can be the same as the diodes of only 1 to 3 watts.
The 980 nm class lasers take advantage of the tissue’s 70% water content, which allows the high absorption of its radiant light energy into the tissue to significantly enhance the laser’s ablating (vaporizing/cutting) efficiency. Additionally, the 980 nm wavelength allows for water irrigation to be used while ablating, enabling convection cooling to the surrounding tissue to control collateral thermal damage.
Also, the fact that the fiber does not need to be initiated enables the absorption of its radiant light energy in the tissue’s other chromophores of hemoglobin, oxyhemoglobin, and melanin even though the percentage of these is greatly less than water.
The fiber tip of 980 nm class laser can also be initiated and the laser can then perform in the same manner of direct contact conductive heat transfer as the 810 nm class lasers; however, this will negate the real benefit of the 980 nm radiant energy absorption and cooling of the surrounding tissue with water irrigation. By having the ability to use either radiant or conductive energy transfer and convection cooling possibly makes the 980 nm class of lasers the ideal wavelength for soft tissue ablation.
Controlling the amount of energy in each pulse of the laser light and the amount of time that it interacts with the tissue also has a significant impact on the laser’s efficiency. There is a linear relationship between the energy in a pulse of light energy and its ablation efficiency.
Increasing the laser power lowers the ablation threshold and accelerates the ablation process. This increased efficiency causes a decrease in the side effect of collateral thermal damage. Thus, the higher the peak power of a laser, the more efficiently it can ablate the target tissue. However, proper control of this energy is required to achieve the optimal outcome.
Controlling the laser energy effects on the remaining surrounding tissue is imperative. The goal in some situations may be to obtain hemostasis, and in others it might be to achieve the proper contour or emergence profile of the gingiva.
Often this is accomplished by managing the length of time the tissue is energized with laser energy relative to the amount of time it is allowed to relax, enabling the surrounding tissue to cool before the next pulse. The more a laser can control its pulse width and emission/duty cycle, the more effective the laser will be in successfully managing the outcome of the remaining surrounding tissue.
Using the high peak power with microsecond pulse features on the simple–to–use but more sophisticated lasers allows specific microscopic tissue to be precisely removed with each pulse. It also allows thermal recovery (thermal relaxation) between each pulse, therefore minimizing any collateral tissue damage and postoperative discomfort.
With a high powered 980 nm diode laser (greater than 6 watts), this precision can be further enhanced by using water irrigation for convention cooling, allowing the clinician to precisely control his or her clinical options and modes of treatment. This is especially important for procedures such as biopsies and sulcular debridement (sometimes referred to as sulcular decontamination).
Laser sulcular debridement as an adjunct therapy to conventional root planing and scaling is one of the most beneficial treatments in laser therapy. The purpose is to remove the diseased epithelium of the periodontal pocket, leaving the healthy tissue intact. The bactericidal effect of the laser energy is also used in this procedure to reduce or eliminate the bacteria of the periodontal pocket as much as possible and to form a stable clot.
The goal of this treatment is to reestablish the attachment to the tooth and reduce the pocket depth without losing any additional height of the gingival crest (recession). The goal of all laser treatment is to use the least amount of average laser energy necessary to achieve the desired response.
The use of minimally invasive soft tissue laser therapy is rapidly becoming part of the standard of care for initial to advanced periodontal therapy and various other soft tissue procedures. There are increasingly significant differences being introduced in dental lasers and it is important to understand the value of these enhancements.
It is the responsibility of all clinicians to become knowledgeable about the science of laser physics and to select the best devices for their practices. It is imperative that each practitioner become properly trained specifically on the lasers they are using to offer the best patient care possible.
Wednesday, February 24, 2010
Pneumonia is the leading cause of death in elderly nursing home residents, Dr. Carol W. Bassim and colleagues point out in the Journal of the American Geriatrics Society. "Several studies have shown that poor oral hygiene or inadequate oral care are also associated with pneumonia," they add.
Bassim, now at the National Institute of Dental and Craniofacial Research in Bethesda, Maryland, and her associates studied the impact of enhanced oral hygiene care for residents in two wards at a Florida nursing home compared with residents in two other wards.
Initially, there was no difference in the mortality rate from pneumonia between the two groups. However, patients in the oral care group were older and more disabled than those who did not receive oral care, and once this was taken into account the risk of dying from pneumonia was more than three times higher in patients who did not receive oral care.
Pneumonia in the elderly is often triggered by aspirating saliva or food. It is likely that the risk of pneumonia "depends on the quality and the quantity of the oropharyngeal contents of a patient at the time of respiratory inoculation or introduction," Bassim and colleagues explain.
"The quantity of saliva inhaled and a predisposition to gross aspiration events may not be modified through oral care," they add, "but this study indicates that oral care may be involved in significantly reducing the harmful quality of the intra-oral environment, reducing the risk of a patient dying from pneumonia."
SOURCE: Journal of the American Geriatrics Society.
Stomach Ulcer Bug Causes Bad Breath
"Recently, scientists discovered that H. pylori can live in the mouth," said Dr Nao Suzuki from Fukuoka Dental College in Fukuoka, Japan. "We wanted to determine whether the bacteria can cause bad breath, so we tested patients complaining of halitosis for the presence of H. pylori."
The researchers found the bacteria in the mouths of 21 out of 326 Japanese people with halitosis (6.4%). In these people, the concentration of a bad breath gas and the level of oral disease was significantly higher. In patients with periodontal (gum) disease, 16 of 102 people (15.7%) had H. pylori in their mouths.
"Halitosis is a common problem in humans, and bad breath is largely caused by periodonitis, tongue debris, poor oral hygiene and badly fitted fillings," said Dr. Suzuki. "Bacteria produce volatile compounds that smell unpleasant, including hydrogen sulphide, methyl mercaptan and dimethyl sulphide. Doctors often measure the levels of these compounds to diagnose the problem. Gastrointestinal diseases are also generally believed to cause halitosis."
Patients who were carrying H. pylori had more blood in their saliva and were also carrying Prevotella intermedia, which is one of the major periodontal bacteria.
"Although the presence of H. pylori in the mouth does not directly cause bad breath, it is associated with periodontal disease, which does cause bad breath," said Dr. Suzuki. "We now need to look into the relationship between H. pylori in the mouth and in the stomach. We hope to discover the role of the mouth in transmitting H. pylori stomach infections in the near future."
Suzuki et al. Detection of Helicobacter pylori DNA in the saliva of patients complaining of halitosis. Journal of Medical Microbiology, 2008; 57 (12): 1553 DOI:
"I floss twice a day; once at night before I go to bed and then in the morning when I wake up," Stein said. "Sometimes I floss in between, too, if I need to."
Stein's habit of flossing often will not only benefit her oral health, but can also benefit her body's overall health. In fact, that little piece of string that Stein keeps in her purse has the ability to add up to 10 years to her life span.
Flossing has its dental benefits preventing gingivitis and other gum diseases, but a recent study published in "Circulation: Journal of the American Heart Association" looked at the link between the mouth and chronic diseases.
Faith Yingling, director of Wellness, said the study found people with higher blood levels of specific disease-causing bacteria in the mouth were more likely to experience hardening of the arteries in the carotid artery in the neck.
"Atherosclerosis, also called 'hardening of the arteries,' develops when deposits of fats and other substances in your blood begin to stick to the sides of your arteries. These deposits, called plaques, can build up and narrow your arteries, clogging them like a plugged-up drain," Yingling said. "If these plaques ever block theblood flow completely, you could have a heart attack or stroke, depending on the location of the blockage."
Bacteria from the mouth can enter the bloodstream through the gums and this has been found among artery plaque, which directly contributes to arterial blockage.
Lee Meserve, a biology professor and pre-dentistry adviser at the University, said when it comes to the spaces between the teeth where plaque hides, brushing vigorously won't be enough to remove it.
"Plaque is essentially a collection of microorganisms that like it where it's dark and moist," Meserve said. "Some of those mircoorganisms could potentially spread to the rest of the body."
When people floss they are removing that plaque and harmful bacteria from between the teeth, which in turn helps prevent gum inflammation -- another way in which mouth infections can affect the rest of the body.
"One of the body's natural responses to infection is inflammation (swelling)," Yingling said. "It's possible that as these oral bacteria travel through your body, they trigger a similar response, causing the blood cells to swell. This swelling could then narrow an artery and increase the risk of clots."
Health professionals agree on the benefits of flossing, but disagree when it comes to how many years flossing can add to a person's life span.
No matter how many years flossing can add to a person's life, it can still help prevent heart disease while also preventing bad breath moments.
"[Flossing] can also help prevent cavities, gingivitis, and tooth loss," Yingling said. "In the short-term, flossing can help reduce tartar build-up, remove food particles and plaque, and improve the smell of breath."
The proper way to floss according to the American Dental Hygienists' Association (provided by Dr. Faith Yingling):
- Wind 18" of floss around middle fingers of each hand. Pinch floss between thumbs and index fingers, leaving a 1"- 2" length in between. Use thumbs to direct floss between upper teeth.
- Keep a 1" - 2" length of floss taut between fingers. Use index fingers to guide floss between contacts of the lower teeth.
- Gently guide floss between the teeth by using a zig-zag motion. Do not snap floss between your teeth. Contour floss around the side of the tooth.
As this body of research surrounding the Oral-Systemic Connection has grown scientists from all directions have discovered that they are all looking at the same thing. Systemic inflammation is now considered to be one of the dominant common denominators in many of today’s major illnesses. We now know that increased pro-inflammatory proteins in the body (i.e. cytokines and chemokines) has profound life and death consequences.
• Pregnancy complications soar by a factor of 255% for women with gum disease. (Ask any physician about the oxytocic effects of increased PGE2 levels during pregnancy!)
• For diabetics, mortality in adults without gum disease rises from 3% to almost 28% when gum disease is present.
• C-reactive protein is now recognized as a more significant risk factor for heart disease and strokes than is high cholesterol levels.
• Cancers of inflammatory origin (colon), Alzheimer’s disease, osteoporosis, kidney disease, and other diseases and conditions related to systemic inflammation are now entering this arena.
Suddenly, dentistry is beginning to take a more central role in the quest to identify and remove sites of chronic infection and inflammation within the body. This sudden increase in scientific literature and research is destined to continue to grow, no doubt snowballing its way onto the front stage of modern dentistry and medicine. Indeed, many physicians and medical specialists are aware of these changes, but many are as yet unsure what to do about it.
Physicians now find themselves in a particularly vulnerable spot. They will be held accountable by malpractice attorneys and the new standards-of-care, for people with gum infections – especially if they have heart attacks, strokes or have pregnancy complications or diabetes.
Wednesday, January 27, 2010
How scary! There is now proof that gingivitis in pregnant women can be deadly ... for your baby.
Scientists from Case Western University have linked bacteria from a mother's gums to an infection in a baby that was full-term but stillborn, reports Obstetrics and Gynecology.
A 35-year-old California woman's gums bled heavily during her pregnancy, and her baby was stillborn. Plaque samples from the woman's teeth were found to be positive for the same strain of the oral bacteria found in the dead baby's stomach and lungs.
Gingivitis can increase the risk of preterm birth anywhere from twice to seven times, researchers say.
OB/GYN and momlogic expert Dr. Gilberg says: "This is such a tragedy. Term still birth is still pretty rare -- about 2/1,000 live births -- with poor or no prenatal care being the largest risk factor. Just over 50% of these deaths are unexplained, meaning we just don't know what caused the demise, or we cannot prove it. So the fact that this woman was able to sleuth enough to find a cause, and that this was preventable, makes it even sadder. To put it into its proper perspective, this sad story is a case report -- in other words, the first documented situation of its kind. But it does make you wonder how many other stillbirths whose cause was never discovered might be linked to dental complications."
She continues: "It is true that between 50-75% of pregnant women may experience the more benign forms of pregnancy gingivitis -- tender, swollen, bleeding gums. The risks of preterm labor and resulting prematurity associated with dental problems in pregnancy are well-documented, but it turns out that hormones and increased fluid levels are not the only culprits. Our overall inattention to our oral health is at fault, and if we'd just do what the dentists (and our moms) have begged us to for ages, most of us could avoid this nuisance, or worse!"
Dr. Suzanne has a confession: "I must admit that I got four cavities during my first pregnancy -- that's right, your good old Dr. Suzanne also committed the crime of falling WAY behind in her oral hygiene but I was an OB/GYN resident at the time) ... so, please brush, floss, and irrigate daily BEFORE and after conceiving. See the dentist REGULARLY before and during pregnancy! Just do it!"
More info Pre Term Low Birth weight babies