Results from a study in Malawi showed that chewing gum containing xylitol, a naturally occurring alcohol sugar, was associated with a 24% reduction in preterm birth, researchers said.
The team found that the group of pregnant women randomised to receive chewing gum also saw a 30% drop in low-birthweight babies, compared with the control group which did not receive xylitol gum, according to lead author Dr Greg Valentine, associate professor of paediatrics at the University of Washington School of Medicine.
“It surprised us all that such a simple intervention could have such a dramatic effect,” he said.
The study followed two randomly selected groups of patients over three years in Malawi with more than 10 000 participants, noted senior author Dr Kjersti Aagaard, medical director of HCA Healthcare, who started the study at Baylor University.
A total of 4 549 patient participants received the xylitol chewing gum intervention while 5 520 in the control group received traditional counselling and medication. The study was conducted from May 2015 to October 2018. The data analysis and follow-up was completed in October 2021.
The findings were published in Med 50 (a Cell Press journal).
Previous research has shown that, during pregnancy, periodontal disease (or gum disease) is associated with a two- to threefold increase in risk for preterm birth and low-birthweight delivery.
While little evidence exists to identify the mechanism behind this link, it might be explained by the inflammatory response associated with periodontal disease, or through the spread of bacteria from the mouth through the bloodstream to organs throughout the body, the researchers surmised.
In humans, 1mm of dental plaque contains 100m bacteria, including pathogens. These bacteria can cause infection and inflammation throughout the body, the report stated.
Xylitol is a naturally occurring sugar alcohol sweetener used in chewing gum, lozenges and candies that have probiotic properties. Studies have shown that xylitol can both reduce the growth of bacteria strongly associated with periodontal disease and independently reduce inflammation in gum tissues, researchers noted.
In the Prevention of Prematurity and Xylitol trial, participants were enrolled before they became pregnant and in early pregnancy (before 20 weeks’ gestation) and followed until birth.
Trying to treat periodontal disease via traditional methods, such as deep cleaning to remove plaque under the gum tissue, and encouraging the use of toothbrushes and toothpaste, is difficult in low-resource countries due to lack of supplies, shortages of healthcare workers, and the lack of clean running water, Valentine said.
A simple intervention like chewing gum helps overcome those issues by improving oral health in a more accessible manner, he said.
The individuals enrolled in the trial in eight Malawi health centres chewed xylitol-containing gum from early pregnancy until delivery.
“Basically, we know that periodontal disease is associated with preterm birth,” Valentine said. “This is particularly significant in Malawi, since about 70% of pregnant women suffer from gum disease.”
Malawi has one of the highest incidences of preterm birth worldwide, occurring in up to 20% of births, the researchers noted. Preterm birth is the leading cause of death worldwide for children under five, the report noted.
Valentine is leading another Malawi trial, the Prevention of Developmental Delay and Xylitol study, which follows 1 000 children born during the initial trial to study neurodevelopmental outcomes between four and eight years of age.
That study seeks to evaluate whether xylitol in pregnancy affects the children’s development, growth, hearing and vision. The study is important to ensure no long-term harm occurred to children exposed to xylitol, Valentine said. Those results are expected in 2027.
The researchers plan to test the xylitol-gum intervention in pregnancies in lower-resourced communities in a US area, he added.
Study details
A cluster randomised trial of xylitol chewing gum for prevention of preterm birth: The PPaX trial
Gregory Valentine, Kathleen Antony, Haleh Sangi-Haghpeykar et al.
Published in Med 50 on 13 November 2024
Context and significance
While periodontal disease in pregnancy is associated with the delivery of preterm and low-birthweight newborns, trials of routine treatment strategies have not shown significant benefit. Here, investigators evaluated the use of xylitol-containing chewing gum among 10,069 pregnant participants in an eight-site cluster randomised trial in Malawi, a country with one of the highest preterm birth rates. Compared to an active control group receiving education and Malawi Ministry of Health standard prenatal care, early pregnancy initiation and ongoing use of xylitol-containing chewing gum twice daily reduced the occurrence of preterm and low-birthweight deliveries. In order to prevent one such occurrence, fewer than 26 gravidae needed xylitol chewing gum use, making it efficacious and affordable in a low-resource setting.
Summary
Background
Maternal periodontal disease is associated with preterm and low-birthweight deliveries, but randomised trials of likely efficacious treatments (e.g., dental scaling and root planing) during pregnancy have not reduced these adverse outcomes. As an alternative, we hypothesised that periconception initiation of xylitol chewing gum would reduce the occurrence of preterm or low-birthweight deliveries among a historical high-prevalence population in Malawi.
Methods
We conducted an open-label, parallel-enrolment, matched-pair, cluster-randomised, controlled clinical trial across eight health centres (sites) in and around Lilongwe, Malawi. Sites were paired by anticipated delivery volume and randomised to prenatal and oral health education alone (active control) or with twice-daily xylitol chewing gum (intervention) throughout the periconception and antenatal periods. For the primary prevention of preterm (<37 weeks) and low-birthweight (<2,500 g) deliveries (co-primary outcomes), comparison by allocation group was performed using generalised linear mixed models for each outcome as a fixed factor and the site(s) as a random factor. Findings A total of 10,069 participants were enrolled (n = 4,549 at intervention sites, n = 5,520 at active control sites), with >95% available for analyses. Initiation of xylitol chewing gum resulted in significant reductions in the co-primary outcomes: preterm birth (12.6% [549/4,349] vs. 16.5% [878/5,321]; relative risk [RR] 0.76, 95% confidence interval [CI] 0.57–0.99) and <2,500-g neonates (8.9% [385/4,305] vs. 12.9% [679/5,260]; RR 0.70, 95% CI 0.49–0.99). Xylitol chewing gum use also led to fewer neonatal demises (0.2% [8/4,305] vs. 0.4% [22/5,260]; RR 0.41, 95% CI 0.19–0.89).
Conclusions
Periconception initiation and ongoing use of xylitol chewing gum significantly reduced the occurrence of preterm and low-birthweight deliveries in Malawi.
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