When do we decide that something is now a fact?

Dec. 1, 2011
Those of us who were in dental school about 30 or more years ago were taught that smoking stains the teeth, but otherwise has no effect on the oral cavity. Anyone who advanced that type of thinking today would not be taken seriously, or worse

Richard H. Nagelberg, DDS

For more on this topic, go to www.dentaleconomics.com and search using the following key words: periodontal disease, oral-systemic, cardiovascular disease, diabetes, atherosclerosis, Richard H. Nagelberg, DDS.

Those of us who were in dental school about 30 or more years ago were taught that smoking stains the teeth, but otherwise has no effect on the oral cavity. Anyone who advanced that type of thinking today would not be taken seriously, or worse.

Other concepts accepted as fact back then included the idea that all bacteria in the oral cavity contributed to gum disease, and that the bacteria secreted acid that severed the gingival attachment. Masks and gloves were reserved only for cases in which the patient or provider had a cold, a cut or abrasion on the hands, cold sores, etc.

Uncovered fingers were routinely placed in patients' mouths, all day long. Clinicians scoffed at oral-systemic associations. The old focal theory of infection was ridiculed.

So when and how does knowledge advance to the point where new ideas become accepted as facts? The obvious answer is primarily through research that reveals new findings. When a body of research has been undertaken that consistently shows the same or a similar finding, it is eventually incorporated into the profession, and treatment approaches are changed that improve outcomes.

It is not a purely linear series of events in which all the research leads to a conclusion. Bits and pieces of research from a wide variety of sources start to reveal a pattern, and further findings fill in the gaps, not unlike a puzzle. The associations between oral and systemic diseases and conditions are at the point in which the picture is now recognizable, even though all the gaps have not been filled in.

It is a picture of a whole body with a wide variety of interconnected parts and systems affecting one another to varying degrees. There isn't a gate or valve in the neck that separates the parts above from the parts below. The oral cavity is just another part of the body.

There are a large number of facts that are now universally accepted, demonstrating some of the associations between the mouth and the body. Among the most obvious is diabetes, which is the No. 1 systemic risk factor for periodontal disease. It is also a fact that periodontal disease increases insulin resistance.

Any infectious or inflammatory condition increases insulin resistance. When a physician is monitoring a well-controlled diabetic patient's glycemic control over a period of time, the first cause suspected when a sudden spike in blood sugar occurs is an infection in the body. Periodontal disease has both infectious and inflammatory components, another universally accepted fact.

Another accepted fact in the health professions is the inflammatory nature of atherosclerosis. For a long period of time, atherosclerosis was considered to be a lipid-driven disease in which cholesterol accumulated in arterial walls. Atherosclerosis is now known to be an inflammatory disease, with the lipid accumulation occurring as a result of inflammatory-driven damage to the endothelium.

Endothelial cells line the inside of arteries. The entire endothelium is only one cell layer thick. Inflammatory damage to the endothelium kicks off the series of events that culminates in arterial plaque accumulation, increasing the risk for a heart attack or stroke. It is also an accepted fact at this point that one of the primary causes of atherosclerosis is insulin resistance.

So we now know that periodontal disease has significant infectious and inflammatory components and that it increases insulin resistance. Chronic inflammation and insulin resistance are both primary causes of atherosclerosis, and atherosclerosis is the primary driver of heart attacks and strokes.

Health-care professionals, including dentists and hygienists, arrive at conclusions and make decisions about incorporating research findings, new technologies, and treatment modalities on a continuous basis. Some are early adopters and others wait for more data before making a decision.

We must keep the patient's best interests in the forefront of our mind. It's easy to get stuck in the minutiae of research. Our patients are not best served if a decision is made on one piece of research. On the other hand, failing to act when a large body of research demonstrates an association denies patients of the benefits derived from the increase in knowledge. We decide that something is now a fact when we are sufficiently convinced of the validity of research results and conclusions.

Dr. Richard Nagelberg has practiced general dentistry in suburban Philadelphia for more than 28 years. He is a speaker, advisory board member, consultant, key opinion leader for several dental companies and organizations, and lecturer on a variety of topics centered on understanding the impact dental professionals have beyond the oral cavity. Contact him at [email protected].

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