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The End Goal of Periodontal Therapy is Improvement of Oral Health and Quality of Life Through Preservation of the Dentition
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The plethora of research studies linking periodontal disease to a variety of serious medical conditions, which have made their way into not only the peer-reviewed literature but also into professional outlets and the lay press, leave clinicians in a quandary as to how these findings should impact patient care. It is paramount for clinicians to have a critical eye when evaluating the literature and remember that association does not imply causality. Methodological pitfalls such as common underlying factors which increase the risk for both periodontal disease and a medical condition can lead to inappropriate conclusions of causality. Various types of confounding, bias, and use of surrogate outcomes may obscure detection of a true clinical endpoint.
- If it could be determined that periodontal disease does cause the initiation or exacerbation of a serious medical condition, that knowledge would improve disease management by dentists and physicians; however, if the presumed associations are spurious, resources could be wasted, and patient care mismanaged. Diagnosis of periodontitis should prompt patient counseling about the possible elevated risk of systemic conditions and possible medical referral. Currently, as there is weak scientific evidence for such associations and no evidence of causality, the main focus of treating periodontal disease lies squarely in preservation of the dentition to improve oral health and quality of life.
abstract
This abstract is available on the publisher's site.
Access this abstract now Full Text Available for ClinicalKey SubscribersIn the latter part of the 20th century, peer-reviewed research began to appear documenting the co-occurrences of periodontal disease and several serious medical conditions, including cardiovascular disease (CVD),1,2 stroke,3,4 diabetes,5 respiratory disease,6 and poor birth outcomes.7 These initial studies spurred additional investigations, and over the past 20 years many additional associations began to appear in the literature, including links with erectile dysfunction,8 obesity,9 cognitive decline,10 rheumatoid arthritis,11 and speculation that periodontal disease can increase complications of COVID-19.12 There continues to be an outpouring of research in peer-reviewed journals, mostly confirming these initial findings. In addition, as the scientific literature expanded, this evidence was disseminated through professional outlets such as clinical newsletters, internet newsfeeds, and clinician blogs. In addition, articles began to appear regularly in the lay press, aimed at a public often poorly equipped to make sense of the science.
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Periodontal disease and medical maladies: What do we really know?
J Am Dent Assoc 2022 Jan 01;153(1)9-13, E Abt, S Kumar, RJ WeyantFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
Many peer-reviewed publications since the 1990s reported associations between periodontal disease and a wide range of serious health conditions, including cardiovascular disease, stroke, diabetes, respiratory diseases, poor birth outcomes, erectile dysfunction, obesity, cognitive decline, rheumatoid arthritis, and others. The sheer volume of research in this area has led many observers to conclude there is a causal link between periodontal disease and the onset or progression of serious medical conditions. But, as the authors of this commentary point out, association is not causation. Nearly all of these studies used similar observational study designs, so perhaps it is not surprising that they largely share the same inherent limitations. Most chronic diseases have complex, multifactorial causal pathways and it is difficult or impossible in cohort or case-control studies to completely account for confounding factors, selection or measurement error, or underlying biologic mechanisms that may be involved in the etiology or progression of periodontal disease as well as the medical condition under study. The strength of association in published studies typically is quite modest and cannot adequately rule out alternative explanations. The inherent limitations of observational studies remain, even after conducting systematic reviews of those studies and combining their data in meta-analyses. Randomized controlled trials can provide much stronger evidence of a causal relationship between periodontal disease and subsequent medical outcomes by better controlling for known and unknown confounders while testing whether treating the causal condition (periodontal disease) reduces the onset or severity of a resulting health outcome. So far, no studies have confirmed that periodontal interventions lower the risk for myocardial infarction, stroke, death, or poor pregnancy outcomes, and a high-quality systematic review judged the evidence as low regarding improvement of glycemic control. As the authors note, periodontal disease remains a potential risk factor for serious medical conditions even in the absence of an established causal link. However, the authors’ bottom-line conclusion is that the main reasons for treating periodontal disease remain the preservation of the dentition and improvement of oral health and quality of life. Because the oral-facial complex is an integral part of the human body, perhaps future studies on the impact of improved oral health on other health outcomes can be better captured by measures other than clinical signs of periodontal disease and a variety of disease-specific endpoints.