As National Smile Month continues, Dr Victoria Sampson sets out how sugar-free gum could contribute to reducing the number of preterm births globally, particularly in countries lacking significant health infrastructure.

The usefulness of chewing Sugar-Free Gum for the maintenance of good oral health has long been appreciated by dentists. Sugar-Free Gum has been shown to increase saliva production, neutralise acids in the saliva, remove food from the oral cavity and help keep the mouth clean. Yet until recently, its wider 'whole body' health benefits have been overlooked.

With National Smile Month in full swing, there is perhaps no better moment to discuss this often-overlooked link between the mouth and wider general health.

Over the last 20 years, a growing body of research has emerged linking periodontitis (gum disease) with a host of systemic health problems. Diabetes, cardiovascular disease, Alzheimer's, and even preterm birth have been found to have a connection to poor oral health.

The link to preterm birth is particularly surprising. However, multiple studies have recently been published illustrating the connection between oral diseases and adverse outcomes in pregnancy.

In February this year, American researchers in South-East Africa published the results of a six-year study of over 10,000 pregnant women in Malawi. This study looked at whether improving oral health would improve pregnancy outcomes.

They asked half the study group to chew xylitol-based sugar-free gum (SFG) for 10 minutes once or twice a day whilst the other half were asked not to. The results showed that good oral health improved maternity outcomes with the group chewing sugar free gum experiencing a 24 per cent reduction in the overall rate of preterm delivery as well as a 31 per cent reduction in the number of babies weighing less than 5.5 lbs.

The study`s lead author, Dr Kjersti Aagaard, an expert in maternal-foetal medicine at Texas Children's Hospital concluded that "Using xylitol chewing gum as an intervention prior to 20 weeks of pregnancy reduced preterm births, and specifically late preterm births between 34 to 37 weeks."

Considering the high costs of other prenatal programmes that might otherwise be used to get this kind of result, the fact that this was achieved at a cost of $40 per patient (the retail cost of the chewing gum) is extraordinary.

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Malawi has one of the highest premature birth rates in the world, accounting for anywhere between 7.9 and 29.7 per cent of all pregnancies in the country. For reference, in Britain the rate is about 7.7 per cent premature births, amounting to roughly 60,000 babies born before 37 weeks of pregnancy.

There are a number of potential reasons why poor oral health may be related to preterm birth and adverse pregnancy outcomes. Research by the Institute of Child Health in London in 2014 discovered that the bacteria fusobacterium nucleatum, which is found in the mouth, was also present in the amniotic fluid and placenta of pregnant women who gave birth prematurely.

A 2017 literature review by the School of Nursing and Health Studies at Georgetown University in Washington DC, sought to establish patterns in oral health across the lifespan of a woman. It too found that "preterm birth, low birth weight, and poor glucose control have been linked with periodontal infection during pregnancy".

They found there was a "bi-directional relationship" between the health of the oral microbiome and pregnancy. Furthermore, as hormonal changes occur in the body during pregnancy, the susceptibility of women to oral infections like periodontal disease rapidly increases.

In turn, periodontal disease can cause inflammatory responses throughout the body, significantly increasingly the likelihood of preterm delivery, low birthweight, and even miscarriage. In the words of lead author, Julia Lange Kessler, "The mouth is the gateway to the body".

The implications of preterm birth are significant. A 2007 study by the Institute for Social Research at the University of Michigan looked at the impacts of low birth weight on adult health. It found that low birth weight increased the probability of dropping out of high school by a third; reduced annual earnings by 15 per cent; and burdened people in their 30s and 40s with the health of someone 12 years older.

According to the World Health Organisation, premature birth is also a leading cause of death around the world. According to its estimates, roughly 15 million babies are born early each year. These new-borns suffer a much higher risk of death immediately following birth, and many will go on to develop debilitating health problems in later life.

The results of the Malawi study suggests that Sugar-Free Gum has an important part to play in tackling the problem of preterm birth. By cleaning the mouth, it can help guard against oral health problems like periodontal disease and gingivitis, and thereby reduce knock-on risks to the foetus.

"What's unique about our study is that we used a readily available, inexpensive, and palatable means to reduce the risk of a baby being born too soon or too small," said Dr Aagaard.

Simple, cheap, easily-accessible, preventative measures are particularly important in countries like Malawi, which lack medical infrastructure and dental care facilities. These can save a lot of money and, most importantly, lives.

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