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Oral Health Systemic Health: What's the Evidence

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Oral Health Systemic Health: What's the Evidence The Oral Health Systemic Health Connection: What’s the Evidence? THOMAS M. PAUMIER DDS Oral Health Systemic Health Connection Are there systemic medical conditions which cause or lead to the progression of periodontal disease or periapical pathology? Does periodontal disease or periapical pathology cause or lead to the progression or worsening of systemic medical conditions? Introduction Question 1 Question 2 Focal Infection Theory Metastatic spread of infection from the mouth as a result of transient bacteremia Metastatic injury from the effects of circulating oral bacterial toxins Metastatic inflammation caused by immune response induced by oral bacteria Bacteremia ….. Infective Endocarditis/PJI Ulcers ……. Heliobacter pylori Introduction Question 1 Question 2 Current Research Nearly one third of all recent periodontal research 57 different systemic disease conditions Bi-directional relationship Observational studies vs. Randomized Controlled Trials Association vs Causality Surrogate evidence vs. Direct evidence Methodology Introduction Question 1 Question 2 Challenges to Conducting Quality Research How to define periodontal disease Attachment loss, pocket depths, bone loss, BOP, mobility Tooth loss, edentulism (surrogate markers) Clinical exam, chart review, patient self report Length of time since diagnosed with periodontal disease Treatment protocols ….. Root planing, surgery, antibiotics Response to treatments …… maintenance, relapse, refractory cases Length of time following treatment and disease improvement Confounders Introduction Question 1 Question 2 Challenges to Conducting Quality Research COMMON RISK FACTORS FOR PERIODONTAL DISEASE AND SYSTEMIC DISEASES (confounders) Smoking Diabetes Obesity Metabolic Syndrome Age Others …… Low Ca++, Vit D, Alcohol Consumption, Osteoporosis, Stress Introduction Question 1 Question 2 Observational Studies Researchers simply watch what happens to a series of people in one group CONTROL GROUP …… like group of people who have not had intervention or treatment being studied CASE CONTROL ….. Compares two groups: those with the disease or condition (case) vs a very similar group without the disease or condition COHORT ……people are exposed to a factor of interest (smoking, diet, occupation) and followed over a time period sufficient to allow any effects of that exposure to occur and be measured LONGITUDINAL ….. Data are collected from a number of people over a long period of time ….. Prospective/retrospective Introduction Question 1 Question 2 Randomized Controlled Trial (RCT) Participants are assigned by chance to separate groups that compare different treatments Participants or Researchers cannot choose group Must be a control group …… placebo or no intervention Ethical Considerations of withholding treatment Gold standard Strongest evidence about a particular intervention would come from a RCT with a low risk of bias and large sample sizes Introduction Question 1 Question 2 Research Terminology Odds Ratio (OR): measure of association between exposure and outcome Hazard Ratio (HR): (1) odds of survival no different between the two groups Relative Risk (RR): (>1): risk of developing the disease is higher than other group 95% Confidence Interval: range of values that you can be 95% certain contains the true mean …… narrow vs. wide Meta analysis: combines the results of multiple studies in an effort to improve estimates of the size of the effect (power) or resolve uncertainty when reports disagree P value used to determine whether there is an association between a risk factor and an outcome or whether an intervention produces better results than control …… statistical significance. P value <.05 considered statistically significant OR of 2.5 95% CI (1.8-3.3) Introduction Question 1 Question 2 EVIDENCE PYRAMID Evidence Based Dentistry BARRIERS TO INTEGRATION INTO CLINICAL PRACTICE Must be able to understand and evaluate the literature Know where to look for credible information Resistance to change long held clinical dogmas Reliance on own clinical experience or that of peers Time to read journals and attend CE courses Evidence Based Dentistry (EBD) CHALLENGES AND LIMITATIONS Flossing Controversy Jumping out of an airplane Toilet Paper The absence of evidence does not mean there is evidence of absence Evidence Based Science During a Pandemic Clinical decisions based on case reports and observational studies No time for adequate peer review Everyone will be wrong about something Ability to acknowledge shortcomings rather than saying definitively “the science says” ……. “the best available science to date with the following limitations” Mask use in public setting controversy N = 1 Evaluation of Journal Articles Peer reviewed Journals JADA Journal of Evidence Based Dental Practice Specialty Journals JAMA NEJM Circulation (JAHA) Evaluation of Journal Articles JADA April 2019 SPIN ….Risk of Colon cancer18% higher if eat processed meat (relative risk RR). Risk of colon cancer is 4.5%. Means absolute risk only increases 0.8% from 4.5% to 5.3%. MISINTERPRETATION … authors conclusions are not supported by the study outcomes. INAPPROPRIATE METHODOLOGY … hypothesizing after results are known. Wrong study design, inappropriate statistical tests, inappropriate data analysis Don’t Believe Everything You Read CROSS SECTIONAL ANALYSIS Abstract or Full Text? JADA January 2020 Evaluated 75 Abstracts of RCTs from 9 peer reviewed journals with statistically non significant primary outcomes in 2015 31% revealed existence of SPIN in conclusions Claimed clinical significance, or clinical equivalence or emphasized statistically significant secondary outcomes Quality Research Bradford Hill Criteria Statistical strength of association Consistency Specificity Temporal relationship (cause precedes consequence) Biologic gradient or dose-response relationship Biologic plausibility Coherence Experimental reversibility Analogy …… other precedents Introduction Question 1 Question 2 Association vs Causality Causality requires evidence that the factor precedes the disease Causality requires evidence of knowledge of the mechanism of action of the risk factor on the disease Causality requires evidence that modification of the risk factor will prevent or moderate the disease Introduction Question 1 Question 2 Controversy JADA 2018 Dr. Harold Slavkin IF IT CAUSES EVERYTHING, THEN IT CAUSES NOTHING Introduction Question 1 Question 2 Direct Crown Anterior Direct Crown Anterior Direct Crown Anterior My crown is loose ….. Direct Bonded Bridge PERIAPICAL SYSTEMIC DISEASE PATHOLOGY ASSOCIATION Association Between Apical Periodontitis and Systemic Diseases Systematic Review 2016 American Association of Endodontics Cardiovascular Disease: There is moderate evidence to show an association between endodontic pathosis and CVD: NO cause/effect established Diabetes: Current evidence is inconclusive and insufficient to suggest an association Chronic Liver Disease no good studies Blood Disorders/Hemophilia to show Bone Mineral Density any association Introduction Question 1 Question 2 Apical Periodontitis and Diabetes JADA June 2021 6M patients/7749 dx with AP matched with 7749 controls T2D was independently associated with significantly greater prevalence of AP (OR 2.05) The use of metformin or statins was independently associated with lower prevalence of AP (OR 0.82/0.7) HbA1c > 8 was significantly associated with greater prevalence of AP (OR 2.46) Bioburden and inflammatory mediators shared by both diseases … controlling T2D maintains health by immunomodulatory effect? Or do those with better disease management also have better oral hygiene and diet? Endodontic Lesions and CVD Journal of Endodontics Sept 2018 Systematic Review of Longitudinal Cohort Studies only-- as the temporal association implying causality can be proposed. Studies had high risk of bias and high heterogeneity Level of evidence is low No confidence in results and cannot make conclusion from meta-analysis Recommend better well controlled studies PERIODONTAL SYSTEMIC DISEASE DISEASE ASSOCIATION Periodontal Disease Chronic bacterial infections caused by subgingival dental BIOFILM Virulent organisms cause tissue destruction or trigger destructive immunopathologic host response Over 50% of adult population with nearly 20% having severe disease Affects the systemic immune response Common pathogens: Gram - anaerobes: Porphyromonas gingivalis, Aggregatibacter actinomycetemcomitans, Tannerella forysythia, Prevotella intermedia, Treponema denticola, Fusobacterium nucleatum PMN (neutrophil) dysfunction CHRONIC INFLAMMATION Introduction Question 1 Question 2 Biologic Plausability Inflammation Inflammatory cytokines: - C-reactive protein (CRP) - interleukin-1, interleukin-6 (IL-1, IL-6) - tumor necrosis factor alpha(TNF) - prostaglandin E Bacteremia and hematogenous spread Associated with many chronic systemic diseases Introduction Question 1 Question 2 Biofilm Complex aggregation of microorganisms within a sticky extracellular matrix Adheres to moist mucosal and tooth surfaces and foreign surfaces including dental prostheses, catheters, prosthetic valves and joints Protect embedded slow growing microorganisms from physical dislodgement as well as antibodies, phagocytes, antimicrobials, and antibiotics Associated with Periodontal Disease, Dental Caries, Infective Endocarditis, Coronary Artery Plaques, PJI, VAP and HAP, AV Shunts for Dialysis, UTI and many other infections
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