Beruflich Dokumente
Kultur Dokumente
Center for Evidence-Based Dentistry, The Forsyth Institute, 245 First Street, Cambridge, MA 02142, USA
Centre for Evidence-based Dentistry, University of Oxford, Rewley House, 1 Wellington Square, Oxford OX1
2JA, UK
* Corresponding author.
E-mail address: rniederman1@gmail.com
oralmaxsurgery.theclinics.com
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Fig. 1. Types of studies and levels of evidence. The evidence pyramid is broken into 3 parts. Filtered information
is the highest level. It is so-called secondary research. These reports systematically search for, critically appraise,
distill, and present the results of primary researchunfiltered information. The highest evidence level, with
the highest likelihood of predicting what would occur in ones own practice, and the least probability of bias,
is the systematic review. Conversely, the lowest level of evidence, with the least likelihood of predicting what
would occur in ones practice, and the highest probability of bias is background information (eg, laboratory
and animal studies, cross-sectional epidemiologic studies, and expert opinion or narrative reviews). ( Copyright
2006 Trustees of Dartmouth College and Yale University. All rights reserved. Produced by Jan Glover, Dave Izzo,
Karen Odato, and Lei Wang; used with permission.)
Evidence-Based Dentistry
less prone to bias.7 In other words, epidemiologic
studies were largely contradicted by subsequent
casecontrol studies, and these were largely contradicted by cohort study designs. Finally, trials
using randomization and masking were largely
unchallenged.7 Unfortunately, however, persistent
clinical use of contraindicated concepts and interventions continues long after more definitive
studies are published.8 This leads to significant
variation in care.
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This changed when 3 groups, using crosssectional studies, casecontrol, or cohort methods,
found that cardiovascular disease and preterm low
birth weight were associated with periodontal
disease.1821 More recently, the death of Diamante
Driver from a disseminating oral infection was
a widely reported verification of this concept. The
inductive extrapolation from these and other studies is the following: if oral infections and their
inflammatory mediators disseminate systemically,
and cause morbidity and/or mortality, then one
must provide treatment of oral infections to
prevent systemic maladies.
This hypothesis is appealingly straight-forward.
It makes biological, clinical, and intuitive sense,
and there are cogent supporting examples. This
interest accounts for typical press reports in
January 2011:
Healthy Gums, Healthy Lungs: Maintaining
Healthy Teeth and Gums May Reduce Risk
for Pneumonia, Chronic Obstructive Pulmonary Disease (http://www.sciencedaily.com/
releases/2011/01/110118143224.htm)
Tooth Loss May Be Linked to Memory
Loss. Gum infection may cause inflammation
that affects the brain, researcher suggests.
(http://www.nlm.nih.gov/medlineplus/news/
fullstory_107298.html).
On examination, it turns out that both of the
press-reported studies are cross-sectional, which
can only generate associations. They do not demonstrate causeeffect. And as indicated in the
Table 1
Search strategy and results
Search Step
Search Strategy
# Publications
1.
7,900,989
2.
3.
4.
5.
6.
7.
101,394
36,155
3950
103
1167
1,993
Evidence-Based Dentistry
As straight-forward and clear as these summary
statements are, and they represent the current
highest level of evidence, they contradict the
appealing intuitive hypothesis that oral disease
has an adverse effect on systemic health. Thus
clinicians will naturally balance the conclusions
from a handful of systematic reviews against the
3950 narrative reviews on the same topics, and
their own clinical experiences that identify an
association between oral and systemic diseases.
The sheer number of papers, the biological elegance of the arguments, and the potential impact,
if correct, are powerfully alluring. Interestingly,
however, the narrative reviews largely base their
conclusions on studies of surrogate outcome
measures (eg, bacteria and inflammatory mediators associated with oral infections and systemic
disease), not on the primary outcome of actual
disease. As pointed out by Ioannidis, in the evolution of the focal theory of infection, over-reliance
on lower levels of evidence can lead to false
conclusions.
Five other points are important to note. First,
the periodontal interventions that have been tried
so far are scaling and root planning to treat periodontal disease. Clinical investigators have not yet
examined the potential benefits of antimicrobial
agents that have been found to be very effective in
treating periodontal infections (eg, amoxicillin 1
metronidazole24) and then determined the effects
on systemic disease. Second, as pointed out by
Carl Sagan, absence of evidence is not evidence
of absence. Clinical scientists may have not yet
generated the key clinical question or key clinical
test. Third, reliance on lower levels of evidence
can lead to false conclusions, and the persistence
of these incorrect conclusions can continue long
after definitive studies are published.68 Fourth,
todays litigious society, with legal practices
focusing on malpractice, and the Office Management and Budget Report focusing on overuse,
underuse, and misuse,5 suggest a word of caution.
That is, treatment of oral disease is clearly beneficial in and of itself. However, current evidence
does not support oral treatment for the prevention
of systemic morbidity or mortality. Fifth, given the
dynamic state of discussion around asymptomatic
third molar extraction guidelines,25 the benefits,26
the risks,27 the controversies,28 and the actuarial
life tables,29 one might want to consider decision
cut points for prophylactic care.
REFERENCES
1. Straus SE, Haynes RB, Richardson WS, et al.
Evidence-based medicine. 3rd edition. Philadelphia:
Elsevier Health Sciences; 2005.
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26. Rosemont. White paper on third molar data. American Association of Oral and Maxillofaical Surgeons;
2007. Available at: www.aaoms.org/docs/third_
molar_white_paper.pdf. Accessed July 22, 2011.
27. Jerjes W, Upile T, Nhembe F, et al. Experience in
third molar surgery: an update. Br Dent J 2010;
209(1):E1.
28. Friedman JW. The prophylactic extraction of third
molars: a public health hazard. Am J Public Health
2007;97:15549.
29. Fernandes MJ, Ogden GR, Pitts NB, et al. Actuarial
life-table analysis of lower impacted wisdom teeth in
general dental practice. Community Dent Oral Epidemiol 2010;38(1):5867.