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Public Health Implications of Chronic Periodontal Infections in Adults
Summary Remarks: The CDC Perspective
William R. Maas,
DDS, MPH, Director, Division of Oral Health, Centers for Disease Control and
Prevention
Because this meeting was neither organized nor conducted to achieve
consensus among participants, each departs with a unique take-home message.
The depth of expertise and breadth of backgrounds of the speakers as well
as the mix of attendees enriched both formal discussions and the informal
ones that occurred during breaks. Presenters were particularly responsive
in sharing their thoughts about the public health implications of
associations considered. The discussion periods addressed the two contexts
of periodontitis, i.e., both as an undesirable threat to oral health, in
its own right, and as a potential risk factor for systemic disease.
Throughout this conference, such public health implications were
conditional, predicated on future demonstration of causal relationships and
effective interventions. Based on the current state of the evidence for
these associations and interventions, recommendations for periodontal
treatment on the basis of potential systemic disease outcomes remain
premature. Thus, it seems inappropriate to initiate new public health
programs to prevent these outcomes. It is clearly important, however, to prevent and treat
periodontal infections to maintain and improve oral health.
Clearly, much more research is needed. Where randomized clinical trials
are feasible, they can provide evidence of the effect of periodontal
treatment on systemic outcomes. Another approach would add assessment of
periodontal status to ongoing trials addressing the disease outcomes of
interest. During discussion periods, attendees raised questions about the
costs of and justification for randomized trials, given limited and
inconclusive current evidence from observational studies published in the
peer-reviewed literature. Additional observational studies of
representative populations might permit estimation of potential benefits
from preventing and controlling periodontal infections and guide further
research.
In spite of the preliminary, inconclusive nature of accumulated
evidence, the reported association between severe periodontitis among
pregnant women and their birth outcomes represents one of the more
compelling arguments for public health intervention considered at this
meeting. Although meeting participants focused on treatment of
periodontitis during pregnancy, their discussions only briefly considered
the potential benefits of primary prevention. As a public health goal, it
may be possible to create a situation in which women have healthy gums
before they become pregnant. Then, it is not a large leap to broaden the
commitment and ask what public health aspirations should be for young
adults, both men and women. How can the 15% likely to experience severe
destruction of their periodontium be predicted? How early can persons with
the hyperinflammatory phenotype be identified? Using public health
approaches, could the situation that exists today—many young adults
reaching middle age without ever having early periodontal infection
identified and treated—be rectified?
A second compelling finding, one that should prompt serious thinking
about health care in the United States, comes from data showing that persons with
diabetes report lower use of dental care than do those without diabetes.
This lower use is particularly evident among Hispanics and non-Hispanic
blacks, who are overrepresented among those with diabetes. So, if dental
public health professionals believe that diabetes and its complications are
serious, how should they respond to the fact that many of those who don’t
seek or receive regular dental care are black, Hispanic, or poor? If the
only way to detect those at risk for periodontal destruction is through
clinical assessment, what approaches might increase the number of young
adults with diabetes who receive such an assessment? What interventions
might reach dental and other health professionals, as well as persons with
diabetes and the general public with this important message?
Smoking represents yet a third major issue from this meeting. Because it
is an independent, very strong risk factor both for periodontal infection
and for cardiovascular disease, future research must address whether their
association represents co-morbidity resulting from smoking. Public health
action need not wait for these research findings, however. Good evidence
documents that tobacco cessation counseling provided by dentists and other
dental personnel can be just as effective as that by other health care
providers. For some persons, the dental setting may even be more effective,
because ill effects of the tobacco habit are readily apparent in the
smoker’s mouth. Public policies are making it more difficult for people to
smoke; places to smoke have been reduced, while the cost of cigarettes has
increased. Still, people with nicotine addiction typically must make many
serious attempts to quit smoking before achieving success. Dental personnel
have to accept that such multiple attempts are the nature of this
particular intervention—and thus, they must persist in asking about the
patient’s readiness to quit, as well as in offering encouragement for any
cessation efforts. Given smoking’s role in periodontal infection, dental
clinicians should spend as much time on tobacco prevention and cessation as
on oral hygiene behaviors. Periodontists and their staffs probably ought to
be among the most successful tobacco cessation counselors in all of health
care and could provide leadership for the rest of the dental profession
and the community at large.
Based on what is now known, it seems clear that there are several public
health approaches to explore for preventing and controlling periodontal
infections. The capacity of oral health programs within state and local
health agencies can be built, so they become active partners in broader
ongoing efforts to: a) reduce tobacco use, particularly smoking, at the
individual and community levels; b) educate persons with diabetes and their
health care professionals about the periodontal implications of diabetes and the benefits of regular care; and
c) consider targeted health
communication efforts to make key groups aware of effective preventive
interventions.
While applying what is known, research investments also must occur to
expand the knowledge base. Some of that research will focus on basic
science questions or test interventions with clinical trials, but
substantial needs for epidemiologic, health services, and applied,
community-based research also exist. For example, could susceptible groups
best be reached by adding an oral health component to an existing
intervention trial or ongoing program? This meeting has revealed how far we
have come with the science—yet how far we must still go to achieve the goal
of periodontal health for all.
Back to Chronic Periodontal Infections Conference
Historical Document
Page last reviewed: February 2, 2005
Content source:
Division of Oral Health,
National Center for Chronic Disease Prevention and
Health Promotion |
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