For all the years I've worked at EBN, I've heard dental experts say that part of the importance of dental insurance and regular dental care is that oral health is directly linked to overall physical health - that preventive oral care can reduce the risk of everything from heart disease to low birth-weight babies.
So, imagine my surprise to see a statement this spring from the American Heart Association that says, based on review of more than 500 journal articles and studies, an AHA committee has concluded there's no proof that gum disease leads to heart disease or stroke - or that preventive dental care can reduce the risk of heart attack or stroke. Further, the committee revealed, some dental procedures - including ones to treat gum disease - could even increase the risk.
Wait ... what?
To get a better understanding of the dental industry's position, I spoke to Dr. Bill Kohn, DDD, vice president for dental science and policy at Delta Dental Plans Association. -KMB
EBN: As a dentist and a representative for a major dental insurer, how do you respond to the AHA statement? Do you still believe there is a link between oral health and overall physical health, including decreased risk for heart disease? If so, what evidence have you drawn that from?
Kohn: Certainly, there's a relationship between oral health and general health. The question is: Is there a direct cause-and-effect relationship between [the two]?
As with most studies on this, we're talking about periodontal disease - a bacterially caused infection and there's a lot of inflammation involved. The American Heart Association statement talked about the connection between periodontal disease and vascular diseases, which also have a high inflammatory component.
What [the AHA] said was there's not a direct cause-and-effect relationship between them. Now, that doesn't mean they're not associated in some way, and that's the hard thing to explain in a way that people understand - the difference between cause-and-effect and an association.
In this case, [AHA] is saying, "Yes, there's an association between heart disease and periodontal disease." And the reason that is, is because people with heart disease and people with periodontal disease share some of the exact same risk characteristics - the biggest ones are smoking and diabetes. So, sorting out the effect is a difficult task.
Most of the [studies] for the last decade or more have been epidemiological studies [rather than] the gold standard, which is clinical trials - where you're asking a specific question and you design the trial to answer just that question. Those studies haven't been done for periodontal disease and heart disease, so they can't make any definitive statements on that.
The studies don't support [the conclusion that] if you get periodontal disease treatment that it will lower your risk of having a future heart attack. We can't say that right now.
But what [AHA] did say was that the studies that have been done so far don't support a cause relationship, but they do associate an association.
Some providers have misinterpreted the literature in terms of the difference between an association and cause-and-effect. It's certainly important to get periodontal disease diagnosed and treated, but [dentists] shouldn't tell people that by getting it treated that we're going to prevent a heart attack, a preterm baby or anything like that. The [message] should be treating periodontal disease is important and then beyond that, it's advising patients that if they have periodontal disease and other risk factors that they should talk to their physician. I think that's what the [AHA] was hoping the takeaway would be.
EBN: Like you said, that's a difficult distinction to make - what's cause-and-effect and what's an association. So, how would you advise your colleagues in the dental profession and employers who are offering dental coverage to respond to people who might question whether dental coverage or dental care is necessary?
Kohn: Periodontal disease in and of itself needs to be treated, and the earlier that it's diagnosed and treated, the better. No matter what the association between periodontal disease and cardiovascular disease or other diseases, it's important to diagnose and treat periodontal disease.
So, for that reason alone, you need to get regular exams. Many companies now are offering additional periodontal exams for people with cardiovascular disease or for pregnant women, and we think that's a good thing because people with those conditions are more susceptible to having periodontal problems.
EBN: Since you've made the case for regular dental care, what trends are you seeing in dental benefits? Have you seen the adoption of dental benefits increasing, decreasing or remaining about the same in recent years?
Kohn: During the first few years of the recession, starting in 2007, it appeared that there was a slight decrease in the adoption of benefits, but it's remained steady and since then has picked up. People usually get their dental benefits through their employer, and that's been pretty steady.
Now, people haven't used their benefits to the same extent; they're not getting as many crowns or having high-cost procedures. But in terms of prevention - and [dental plans] are mostly designed to prevent people from getting oral disease - people are still getting their benefits and using them.
From the American Heart Association
The following was taken from an AHA press release on the link between oral health and heart health:
"For more than a century, doctors have proposed that infected gums lead to systemic problems like atherosclerotic heart disease, and that mouth bacteria frequently enter the blood stream during dental procedures and during naturally occurring events such as tooth brushing.
Gum disease and cardiovascular disease both produce markers of inflammation such as C-reactive protein, and share other common risk factors as well, including cigarette smoking, age and diabetes mellitus. These common factors may help explain why diseases of the blood vessels and mouth occur in tandem, but the association between gum disease and cardiovascular disease appears to exist independent of these risk factors in many studies.
Statements that imply a cause-and-effect relationship between periodontal disease and cardiovascular disease, or claim that dental treatment may prevent heart attack or stroke are 'unwarranted,' at this time."
