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Promoting oral health care because of its possible effect on systemic disease is premature and may be misleading

2018; Elsevier BV; Volume: 149; Issue: 6 Linguagem: Inglês

10.1016/j.adaj.2018.03.030

1943-4723

Bruce Lee Pihlstrom, James S. Hodges, Bryan S. Michalowicz, Johan Caspar Wohlfahrt, Raul I. García,

HIV/AIDS oral health manifestations

As oral health care providers, we strive to improve our patients’ quality of life and overall well-being by preventing and treating oral disease. We provide care for patients who have complex medical histories, and we work with physicians to manage or treat diseases, injuries, or other conditions in the orofacial area. We also consult with physicians and provide care for patients who are receiving head and neck radiation, chemotherapy, organ transplantation, joint replacement, invasive cardiac procedures, and many other diseases and conditions. Moreover, dentists often serve as a point of entry to the health care system and screen patients for conditions such as diabetes and hypertension. Despite the vital role that dentistry has in public health and in the lives of individual patients, there seems to be a need for some to justify the value and benefits of oral health care because it may have an effect on “systemic” diseases, defined as diseases that affect the entire body1US National Library of Medicine MedlinePlus. Systemic.https://medlineplus.gov/ency/article/002294.htmGoogle Scholar or several different organs or tissues.2Dorland's Illustrated Medical Dictionary. 32nd ed. Elsevier/Saunders, Philadelphia, PA2012Google Scholar During the past 25 years or so, investigators in many research articles have reported associations between some oral diseases and conditions such as preterm birth, diabetes, cardiovascular disease, stroke, and cancer. The implicit “take-home” message of these studies for the news media, many patients, practitioners, professional organizations, and third-party payers is that preventing and treating oral disease will modify, reduce, or prevent various systemic diseases. The concept that oral disease may cause or exacerbate systemic disease generates media attention and attention-grabbing headlines. Promoting the concept that prevention or treatment of oral disease reduces morbidity, prolongs survival, and reduces the cost of medical care is an attractive strategy for patient recruitment and to justify insurance coverage for oral health care. However, there remains a need for more convincing and higher quality evidence that oral health care actually has a measurable impact on specific systemic diseases before it can be claimed that attaining good oral health can prevent systemic diseases or conditions. It is premature to do otherwise. Simply put, making claims that are not supported by high-quality scientific evidence may damage the credibility of our profession, much like the concept of “focal infection” did a century ago.3Kumar P.S. From focal sepsis to periodontal medicine: a century of exploring the role of the oral microbiome in systemic disease.J Physiol. 2017; 595: 465-476Crossref PubMed Scopus (120) Google Scholar Researchers in studies about possible associations between oral and systemic disease have reported a wide range of results. This is not unexpected because the studies include heterogeneous participant populations and study designs, such as small and large cross-sectional surveys, prospective cohort studies, and clinical trials. Meta-analysis can be useful for assessing the results of multiple studies, but it cannot correct shortcomings of existing studies or data.4Dawson D.V. Pihlstrom B.L. Blanchette D.R. Understanding and evaluating meta-analysis.JADA. 2016; 147: 264-270PubMed Google Scholar The quality and availability of published research, as well as the selection of disease and outcome measures, can lead to considerable variation in results and conclusions. Overall, it must be recognized that it is relatively easy to “cherry-pick” the scientific literature to make a case for or against the potential role that prevention or treatment of oral disease may have on a systemic disease. Although possible causal mechanisms have been proposed and many studies of associations between various oral and systemic diseases have been published, there is still no definitive evidence that treating oral disease has any clinically meaningful effect on the prevention, treatment, or outcomes of any systemic disease. The dental community may be taking a “step too far” in embracing associations of oral and systemic disease as a reason to maintain good oral health. Associations and risk factors are identified in observational studies. Although the results of observational studies are helpful in generating hypotheses that may be definitively tested in clinical trials, they cannot determine whether an intervention, such as prevention or treatment of periodontal disease, has any beneficial effect on other diseases or conditions. For example, investigators in a large observational study of postmenopausal women (n = 57,001) reported in 2017 that self-reported periodontitis was not associated with cardiovascular disease events.5LaMonte M.J. Genco R.J. Hovey K.M. et al.History of periodontitis diagnosis and edentulism as predictors of cardiovascular disease, stroke, and mortality in postmenopausal women.J Am Heart Assoc. 2017; 6https://doi.org/10.1161/JAHA.116.004518Crossref Scopus (45) Google Scholar However, these investigators also reported that edentulism was associated with increased risk of developing cardiovascular disease and total mortality and that periodontitis was associated with a 17% higher mortality rate.5LaMonte M.J. Genco R.J. Hovey K.M. et al.History of periodontitis diagnosis and edentulism as predictors of cardiovascular disease, stroke, and mortality in postmenopausal women.J Am Heart Assoc. 2017; 6https://doi.org/10.1161/JAHA.116.004518Crossref Scopus (45) Google Scholar Researchers in another large observational study of both men and women (n = 7,466) reported that severe periodontitis was associated with increased risk of developing cancer, especially lung and colorectal cancer.6Michaud DS, Lu J, Peacock-Villada AY, et al. Periodontal disease assessed using clinical dental measurements and cancer risk in the ARIC study [published ahead of print January 12, 2018]. J Natl Cancer Inst. https://doi.org/10.1093/jnci/djx278.Google Scholar Given the results of these large studies, it would be tempting to conclude that preventing tooth loss and treating periodontitis lead to less cancer and prolonged survival. However, this would be incorrect and misleading because association cannot prove causation. Importantly, the authors of these studies concluded that additional research is needed to determine if modification of oral disease risk factors would lessen the burden of cardiovascular disease and cancer or prolong survival. Our profession should take a cautious view that whereas oral disease might be causally related to other diseases, the main reason for maintaining good oral health is because it is important in and of itself. Why is it not enough to just help people maintain good oral health and keep their teeth? As oral health care providers, we know that having good oral health has many advantages and that poor oral health has many disadvantages. Effective and efficient chewing, enjoyment of food, pleasing appearance, self-confidence, and freedom from pain and infection are just a few of the benefits of good oral health. Good oral health alone justifies preventing oral disease and maintaining oral health.Good oral health alone justifies preventing oral disease and maintaining oral health. Good oral health alone justifies preventing oral disease and maintaining oral health. The many studies that have been published about the association of oral and systemic health have had an enormous impact on dentistry and its relation to medicine. Clinical and basic oral health research is regularly published in highly respected international medical and biological journals, and dentistry is more closely integrated with medicine than at any time in modern history. There is evidence that providing preventive dental care for people having chronic systemic diseases will improve oral health and lower the cost of dental treatment.7Pourat N, Choi MK, Chen X. Evidence of effectiveness of preventive dental care in reducing dental treatment use and related expenditures [published online ahead of print February 6, 2018]. J Public Health Dent. https://doi.org/10.1111/jphd.12262.Google Scholar Research should continue to explore the association and possible causal relation between oral and systemic health and disease as well as the costs and benefits of preventing and treating oral disease. There is also a critical need for additional research to establish the effectiveness of screening for systemic disease in the dental setting, as well as research into the outcomes of dental care for patients who are receiving treatments such as head and neck radiation, chemotherapy, organ transplantation, joint replacement, and invasive cardiac procedures. However, for most of our patients, the importance of oral health alone is more than sufficient justification to strive for effective prevention and treatment of oral disease by promoting interprofessional education, practice, and research and access to high-quality and affordable oral health care for everyone. Dr. Pihlstrom is a professor emeritus, Department of Surgical and Developmental Sciences, School of Dentistry, University of Minnesota, MN. He also is the associate editor, Research, for The Journal of the American Dental Association, as well as an independent oral health research consultant. Dr. Hodges is a professor, Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN. Dr. Michalowicz is an adjunct professor, Department of Developmental and Surgical Sciences, School of Dentistry, University of Minnesota, Minneapolis, MN. Dr. Wohlfahrt is an assistant professor, Department of Periodontology, Institute of Clinical Dentistry, Faculty of Dentistry, University of Oslo, Oslo, Norway. Dr. Garcia is a professor and the chair, Department of Health Policy and Health Services Research, Henry M. Goldman School of Dental Medicine, Boston University, Boston, MA. Medical-dental integrationThe Journal of the American Dental AssociationVol. 149Issue 9PreviewThe editorial by Pihlstrom and colleagues in the June issue of JADA (Pihlstrom BL, Hodges JS, Michalowicz B, Wohlfahrt JC, Garcia RI. Promoting Oral Health Care Because of Its Possible Effect on Systemic Disease Is Premature and May Be Misleading. JADA. 2018;149[6]:401-403) is inappropriately regressive at a time when dentistry is making progress toward integration with primary care. While the objectivity of the editor is commendable, it is somewhat surprising that he supports indirectly the position of these authors, given his own training in oral medicine and penchant for the oral-systemic connection. Full-Text PDF Chronic inflammationThe Journal of the American Dental AssociationVol. 149Issue 9PreviewI read with dismay and disappointment the guest editorial (Pihlstrom BL, Hodges JS, Michalowicz B, Wohlfahrt JC, Garcia RI. Promoting Oral Health Care Because of Its Possible Effect on Systemic Disease Is Premature and May Be Misleading. JADA. 2018;149[6]:401-403) in the June issue. Pihlstrom and colleagues seem to want to discredit the potential connection between oral health and systemic health. Indeed, they imply that promoting the concept is intended just to recruit patients and justify insurance coverage. Full-Text PDF Using the proper scientific methodsThe Journal of the American Dental AssociationVol. 149Issue 9PreviewI want to thank and concur with the authors of the June JADA guest editorial titled “Promoting Oral Health Care Because of Its Possible Effect on Systemic Disease Is Premature and May Be Misleading” (Pihlstrom BL, Hodges JS, Michalowicz B, Wohlfahrt JC, Garcia RI. JADA. 2018;149[6]:401-403). While our collective arguments for the importance of good oral health would be more convincing to policy makers and to our medical colleagues if there was proof that there was a causal relationship between good oral and positive general health or that poor oral health causes negative general health outcomes, to quote the authors, “There is still no definitive evidence that treating oral disease has any clinically meaningful effect on the prevention, treatment, or outcomes of any systemic disease.” Full-Text PDF Association versus causalityThe Journal of the American Dental AssociationVol. 149Issue 9PreviewI applaud JADA and the authors of the June JADA guest editorial (Pihlstrom BL, Hodges JS, Michalowicz B, Wohlfahrt JC, Garcia RI. Promoting Oral Health Care Because of Its Possible Effect on Systemic Disease Is Premature and May Be Misleading. JADA. 2018;149[6]:401-403). As a clinician and educator in evidence-based health care, and dentistry in particular, one of the main reasons science gets it wrong is squarely in the area of association versus causality. The authors correctly state that observational studies can generate hypotheses showing an association between an exposure and outcome or between oral health and other systemic conditions. Full-Text PDF Oral systemic healthThe Journal of the American Dental AssociationVol. 149Issue 9PreviewPihlstrom and colleagues endeavor to take the high ground in their June JADA guest editorial (Pihlstrom BL, Hodges JS, Michalowicz B, Wohlfahrt JC, Garcia RI. Promoting Oral Health Care Because of Its Possible Effect on Systemic Disease Is Premature and May Be Misleading. JADA. 2018;149[6]:401-403). They argue that oral care is important “in and of itself” and point out that “oral health has many advantages,” including “effective and efficient chewing, enjoyment of food, pleasing appearance, self-confidence… .” Fair enough, but is not the benefit of effective chewing primarily oriented toward systemic health? Moreover, advocating oral health, primarily for the “enjoyment of food, pleasing appearance, self-confidence,” is akin to advocating optimal weight merely so that you can look better in a suit. Full-Text PDF