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Inside research
Preterm pregnancy and prenatal awareness
Periodontal disease and premature birth
Using his expertise in periodontics, microbiology and immunology, Harvey Schenkein, D.D.S., Ph.D., has been investigating the relationship between oral disease and its effects on the body’s immune system.
Schenkein, chair of the Department of Periodontics at the Virginia Commonwealth University School of Dentistry, is now leading a study to examine the link between periodontitis, or gum disease, and premature birth.
Specifically, his team will determine if fetal growth restriction associated with periodontal disease is caused by the body’s immune response to the oral bacteria that cause the disease. The work is a component on the large National Institutes of Health-funded grant being led by Jerome F. Strauss III, M.D., Ph.D., dean of the VCU School of Medicine.
Several studies by other investigators show that gum disease in a pregnant woman can result in adverse pregnancy outcomes such as prematurity and fetal growth restriction, as well as preeclampsia, or high blood pressure in pregnancy.
“Our project may disclose one biological mechanism linking periodontal disease to adverse pregnancy outcomes. If this is the case, a simple blood test for the presence of elevated levels of particular antibodies and dental evaluation could identify women at highest risk,” Schenkein said.
The antibodies he refers to are the anti-cardiolipin antibodies, anti-CL, that may be responsible for mediating problems with the fetus. Previous findings by Schenkein show a strong association between positive tests for anti-CL and women who have had a premature baby in the past.
“Periodontal disease is a modifiable risk factor and treatment could contribute to decreasing the chance of fetal growth restriction and prematurity. We already know that periodontal treatment aimed at lowering the levels of bacteria under the gums also appear to lower the amount of anti-CL in the bloodstream. Therefore, such therapy could be directed at the group of women identified to be at risk,” he said.
For this study, the research team will perform dental examinations of women who have experienced premature labor to determine if they have periodontal disease and to assess its severity. The team will examine blood samples for the presence and function of anti-CL antibodies.
Further, they will examine the placentas from these women to assess the characteristics of the immune reactions occurring in the tissue. This will include assessing the levels of the antibodies in the sera and their biological functions to determine if they have properties that would promote adverse pregnancy outcomes.
According to Schenkein, the anti-CL antibody is commonly found in patients with autoimmune diseases such systemic lupus erythematosis and Antiphospholipid Syndrome, APS. This antibody is thought to be a major factor in promoting fetal loss in women with APS.
“There are effects of periodontal infections that are manifested in other parts of the body, particularly dissemination of bacteria from the mouth into the circulation and then to other organs, however the exact mechanisms by which they become involved in non-oral diseases are not known,” Schenkein said.
Other investigators have found that several types of bacteria and viruses could be responsible for tricking the immune system into producing anti-CL antibodies. These antibodies react with normal substances in the body to create pathology leading to fetal loss. Schenkein’s team hypothesizes that there are at least two important species of bacteria that cause periodontal disease with properties that may allow them to also induce production of these antibodies.
One may be the bacterial pathogen known as Porphyromonas gingivalis, which Schenkein said may be responsible for anti-CL antibodies in periodontal disease patients. The pathogen is found in a high percentage of African-Americans with chronic periodontitis and at higher concentrations in their dental plaque than in other racial groups.
Schenkein, who is the director of the VCU Clinical Research Center for Periodontal Diseases, will collaborate with Thomas Koertge, John Gunsolley, Kimberly Hollaway and Donald Purkall in the School of Dentistry.
Addressing infant mortality and prenatal awareness
For some expectant mothers — particularly those among economically disadvantaged populations — resources for learning how to lead healthy lifestyles before and during their pregnancy are few and far between. That’s where the work of Dace Svikis, Ph.D., professor of psychology and director of Promoting Healthy Pregnancies in the VCU Department of Obstetrics and Gynecology, comes into play.
Svikis, deputy director of the VCU Institute for Women’s Health, has been working to improve pregnancy outcomes among economically disadvantaged African-American populations in Richmond, Va.
According to Svikis, a combination of behaviors, the women’s lifestyles and conditions that may include smoking, substance abuse, poor nutrition, lack of prenatal care, medical problems and chronic illness contribute to poor birth outcomes.
As principal investigator of a new collaborative study supported by the Centers for Disease Control and Prevention, Svikis’ team has proposed an intervention model to improve infant mortality among this population with a focus on the cultural, social and environmental barriers to care.
Svikis is collaborating with Sheryl Garland, vice president for the Department of Community Outreach for the VCU Health System and administrative director of the VCU Center on Health Disparities, Susan Kornstein, M.D., executive director of the VCU Institute for Women’s Health, and colleagues from both the VCU Center on Health Disparities and VCU Institute for Women’s Health.
“Many women served by the VCU Medical Center clinics and hospitals do not recognize the importance of prenatal care and how it can contribute to having a healthier baby. Our project focuses primarily on women accessing the VCU Medical Center, but we are also commited to fostering outreach efforts that help to get the word out to the community at large,” she said.
According to Svikis, the model involves three components. The first calls for each expectant mother to be assigned a health system navigator, who will guide each woman through the system of care and teach her the skills to eventually navigate on her own. The second component will help the health system navigator increase a woman’s level of motivation to participate in prenatal care by offering modest monetary incentives such as gift certificates to reward consistent prenatal care attendance. The third component focuses on the practitioner, including educational training in health disparities techniques to identify and become aware of personal biases and training in more effective communication skills based on motivational interviewing.
“We are truly invested in making a difference in our community, and we are pleased to have received significant input from various community partnership groups,” Garland said.
“This is the first successful research collaboration between the VCU Institute for Women’s Health and Center on Health Disparities, with significant input from various community partnership groups,” added Kornstein. “This is clearly an area that faculty involved in both institutes care deeply about.”
VCU was one of 40 institutions selected nationwide to receive funding through the CDC’s Racial and Ethnic Approaches to Community Health, REACH, U.S. program.
The REACH U.S. program will target five racial and ethnic groups: African-Americans, Hispanics/Latinos, Asian-Americans, Hawaiians/Pacific Islanders and American Indians/Alaska Natives. REACH U.S. activities focus on a range of key health areas that contribute to health disparities, including cardiovascular disease, diabetes, breast and cervical cancer, hepatitis B, asthma, infant mortality and adult immunizations.
Through the REACH U.S. initiative, 18 national and regional Centers of Excellence in the Elimination of Disparities, CEEDS, and 22 Action Communities will be established throughout the country. The CEEDs will serve as national resource centers with expertise in specific ethnic populations and will train additional communities to further spread the impact of REACH activities. The Action Communities will implement and evaluate successful approaches within a specific community to impact population groups, rather than individuals, and focus on key health conditions that contribute to health disparities.
Other VCU faculty involved in the project include Judith Bradford, Ph.D., Susan Lanni, M.D., Lori Keyser-Marcus, Ph.D., Saba Masho, Ph.D., and Tatyana Thweatt, Ph.D.
The proposed model was developed by the Promoting Healthy Pregnancies Coalition, a group of community care providers that includes Richmond Healthy Start, the VCU Medical Center, Children’s Health Involving Parents, Richmond Behavioral Health Authority, Healthy Families of Richmond, Virginia Premier Health Plan, Henrico County Health Department, Chesterfield County Health Department and Richmond City Health District. PHPC has focused on infant mortality for more than 15 years and has established a network of services designed to meet the multiple needs of the predominantly African-American community that they serve.
HIV/STD prevention in pregnant women
Svikis has also been contributing to the work of Jerome F. Strauss III, M.D., Ph.D., dean of the VCU School of Medicine, directing one component of his NIH-funded VCU Center on Health Disparities studies. Svikis’ component looks at an intervention for HIV and STD prevention in pregnant women at risk for alcohol and drug problems.
Svikis’ team recently examined data gathered from an anonymous survey completed by 85 pregnant women attending the VCU obstetrics clinic. The survey asked about practical issues related to the upcoming randomized clinical trial. In addition, it included screening questions for smoking, alcohol and other drug use and examined the relationship between substance use and history of having a premature delivery.
According to Svikis, approximately 17 percent of the sample reported smoking during pregnancy and more than one-third (36.1 percent) were categorized as ‘at risk’ for prenatal alcohol and/or drug problems.
“Unfortunately, the majority of substance use goes undetected. The survey data found that women at risk for illicit drug use were twice as likely to report a previous premature delivery compared to those not at risk for such use — which was 60 percent and 38 percent respectively,” she said.
One of the goals of both this project and the CDC study is to foster communication between patient and practitioner about alcohol and other drug use and to provide referrals to treatment when necessary.
In addition, Svikis’ study works closely with the Outreach component of the VCU Center on Health Disparities Research — a federally funded initiative affiliated with the VCU Center on Health Disparities that conducts research in the field — which had identified smoking as a priority health-risk behavior.
Garland is leading the Outreach component of this study. Her team is exploring strategies for fostering community engagement in efforts to reduce smoking during pregnancy. The goal of the initiative is to identify leaders throughout communities in the greater Richmond area who can assist in disseminating culturally sensitive messages focused on providing information to women about the impact of tobacco use during pregnancy.
Garland said that the messages will be designed utilizing information gathered from women who are currently or have recently received care at the VCU Medical Center. Through community partnerships, the team hopes that critical messages about the effects on unborn children will be shared in forums that will engage families in open dialogues and increase knowledge and awareness in communities where the rate of infant mortality and low birth weight has been disproportionately higher than in other regions.