Ongoing debates

By Richard H. Nagelberg, DDS

Many studies that involve research into oral-systemic relationships conclude with a notation that large interventional studies are needed to understand the effect of periodontal treatment on a variety of systemic conditions. Until a number of such studies are completed, what do we do? Completing these studies will take some time. Do we just sit and wait for the research results? This uncertainty among dental professionals is the consequence of practicing while there are still questions that need to be answered. Virtually every dental professional in the past had to work while awaiting research conclusions; however, the implications were not as impactful for the overall welfare of everyone.

There is a parallel in medicine that is currently being debated. Lipoprotein(a), or Lp(a), consists of LDL cholesterol bound to the protein apo(a). Lp(a) is spoken of as "Lp little a." It has long been suspected of contributing to cardiovascular risk; however, research has been lacking regarding the exact role it plays. According to a 2010 statement from the European Atherosclerosis Society, ‘‘The evidence clearly supports Lp(a) as a priority for reducing cardiovascular risk, beyond that associated with LDL-C. Clinicians should consider screening statin-treated patients with recurrent heart disease, in addition to those considered at moderate to high risk of heart disease."

Doctors at the NIH in this country disagree and indicate that only established risk criteria such as smoking, hypertension, diabetes, etc., should be used and that insufficient evidence supports the use of novel biomarkers. The Mayo Clinic disagrees with the NIH position and indicates that Lp(a) should be tested in individuals with elevated LDL cholesterol, which doesn't respond well to drug treatment. They routinely screen patients for Lp(a) in their Early Atherosclerosis Clinic. Doctors may test for Lp(a) in those who have atherosclerosis and normal cholesterol levels and patients with a family history of early-onset heart disease or a family history of sudden death.

Sound familiar? The same debate is going on in the dental profession regarding oral-systemic links. Why are some health-care professionals and institutions forward thinking and others not so much? If we or a loved one had early atherosclerosis, LDL levels that did not respond to statins, or a family history of sudden death, which type of practitioner would we want to manage our health or the health of our spouse, our daughters and sons, parents, grandparents? Would we want all potential risk elements identified and managed or just the traditional ones? Would we want the fullest picture possible to formulate a treatment plan, or one based on the more established traditional risk factors?

As importantly, which type of dental professional do we want to be? Are we still managing periodontal disease by treating pocket numbers instead of disease? Are we still failing to identify the causative bacteria? Are we still thinking the mouth and body are not connected? Are we justifying our resistance to change with comments such as, "I have always done it this way," "I am getting good results already," or "I was always taught …"?

Our patients want a dental team that gives them their best chance for maintaining or achieving the best oral and general health possible. Health care, including dentistry, is moving toward identification and management of risk elements prior to disease development. What is the downside to identifying bacteria through salivary diagnostics for patients with a strong family history of periodontal disease, cardiovascular disease, and diabetes? What is the downside of communication such as, "Research indicates that gum disease and the bacteria that causes gum disease increases the risk for a variety of conditions in the body"? Is it unethical to address oral-systemic associations within the confines of research findings to date? Institutions such as the Mayo Clinic and the Cleveland Clinic, among others, have outstanding reputations for a reason. There are dental practitioners who would not consider placing implants without a CBCT scan, so they have more information to ensure a successful outcome.

The dental profession as a whole barely resembles the profession of 30 years ago. There have always been early adopters and others late to the party. If you keep up with research developments and modify your approach to patient care accordingly, you will reap the rewards of a favorable reputation. More importantly, your patients will benefit immensely.

Richard Nagelberg, DDS, has practiced general dentistry in suburban Philadelphia for more than 30 years. He is a speaker, advisory board member, consultant, and key opinion leader for several dental companies and organizations, and he lectures on a variety of topics centered on understanding the impact dental professionals have beyond the oral cavity. Contact him at [email protected].