hile the practic- mately involved in this area of monary diseases and gastric
W ing dentist al-
ways has had an appreciation for the impor- tance of oral health, research reports and articles in the lay press during the past 25 years research. What are we, as prac- ticing dentists, to make of all this? What can we authorita- tively tell our patients in re- sponse to their inquiries regard- ing relationships between oral and systemic diseases? problems, as well as a number of systemic infectious diseases. The role of oral sepsis as a cause of systemic disease was championed by William Hunter, a prominent British physician, in a publication7 and a 1910 or so have done much to bring The purpose of this supple- talk at McGill University, this to the attention of our med- ment is to provide an update of Montreal.2 He spoke, with con- ical colleagues and the public at the field that will enable us to siderable hyperbole, of dental large. In particular, the possi- respond with the latest informa- restorations built in, on, and bility that events in the oral tion to questions our patients around diseased teeth which cavity can influence systemic might ask. form a veritable mausoleum of disease has been highlighted by gold over a mass of sepsis to the U.S. surgeon generals re- FOCAL INFECTION THEORY which there is no parallel in the port in 20001 and in numerous The concept that oral conditions whole realm of medicine.2 In reports of investigations into can significantly influence 1919, Rosenow8 published a se- associations and interactions events elsewhere in the body is ries of animal experiments and between oral diseaseparticu- not new, but it has undergone a human case reports supporting larly periodontal diseaseand number of iterations over the the concept of focal infection. He coronary heart disease, stroke, years.2-5 A frequently cited early emphasized the importance of adverse pregnancy outcomes, publication is an 1891 report by cooperation between dentists diabetes and bacterial Miller entitled The Human and physicians, as well as the pneumonia. Mouth as a Focus of Infection.6 necessity of ensuring that the The reported studies have in- Miller was highly attuned to the focus of infection is eliminated cluded epidemiologic studies, in- role of bacteria in disease cau- completely, and he noted that tervention studies and studies sation, as he was working in the tooth extraction by itself might seeking to elucidate mecha- laboratory of Robert Koch, not be sufficient. nisms of action. Results of dif- whose postulates were used to Much of the evidence pre- ferent studies have, at times, establish the microbial etiolo- sented in support of the concept been contradictory, which is not gies of infectious diseases. of focal infection proved, on clos- surprising given the variations Miller proposed a role for oral er inspection, to be anecdotal or in study design, populations microorganisms or their prod- of questionable scientific merit. studied and statistical analyses ucts in the development of a va- Nevertheless, it became com- used in the plethora of reported riety of diseases in sites re- mon practice to extract all en- studies. This, however, creates moved from the oral cavity, dodontically or periodontally in- a dilemma for those not inti- including brain abscesses, pul- volved teeth to eliminate any
JADA, Vol. 137 http://jada.ada.org October 2006 5S
Copyright 2006 American Dental Association. All rights reserved. possible foci of infection, with standing of the limits of epi- by which the data are analyzed the expectation that this would demiologic studies in establish- and the issues involved in study prevent or cure a whole host of ing disease causality9; a design and interpretation. local or systemic problems. markedly enhanced under- Each article presents the cur- standing of the etiology and rent state of the field, indicates A MORE SCIENTIFIC pathogenesis of periodontal dis- questions remaining to be an- APPROACH eases and associated systemic swered and the studies needed By about 1930, the validity of diseases that permits an assess- to accomplish this, and provides the focal infection theory began ment of the biological plausibili- a brief summation that can to be questioned, and investiga- ty of putative interactions; the guide dentists responses to pa- tors found, when they consid- availability of successful meth- tients inquiries. I need to em- ered the available real outcome ods of treating periodontal dis- phasize that the investigation data, that there was no clear ease and endodontic lesions; into oral-systemic disease con- basis for ascribing the occur- and the recognition that bacte- nections is a rapidly advancing rence of much systemic disease ria could in some way be re- area of research, and that new to the presence of oral foci of in- sponsible for diseases that information is constantly ap- fection. As a result, the focus of pearing in the literature. As the dental practice changed such field develops further, we can that restorative dental pro- The investigation into anticipate a time when the vi- cedures re-emerged as the oral-systemic disease sion set out in the surgeon gen- mainstay of most dental treat- erals report will be achieved, connections is a ment plans. However, as a more confirming that dental care and scientific approach was applied rapidly advancing area oral health play a key role in to investigating clinical prob- of research. helping to ensure the overall lems, it became clear that, in good health of our patients. fact, there were situations in Dr. Barnett is a clinical professor, which oral bacteria could affect heretofore had a rather uncer- Department of Periodontics/Endodontics, School of Dental Medicine, University at distant structures, in particular tain etiology (for example, evi- Buffalo, The State University of New York. the case of bacterial endocardi- dence documenting the etiologic He also is the guest editor of this supplement. Address reprint requests to Dr. Barnett at tis in susceptible people. role of Helicobacter pylori in the 112 Hidden Ridge Common, Williamsville, Beginning in the late 1980s, development of gastric ulcers N.Y. 14221-5785, e-mail mlbgums@aol.com. a series of publications regard- not an exact analogy to be sure, 1. U.S. Department of Health and Human ing the association between pe- but a useful one). Services. Oral health in America: A report of the surgeon general. Rockville, Md.: U.S. riodontitis and some systemic In considering the existing Department of Health and Human Services, conditions, especially coronary data, it is important to differen- National Institute of Dental and Craniofacial Research, National Institutes of Health; 2000. heart disease and, to a lesser tiate between those data sup- Available at: www.surgeongeneral.gov/ degree, stroke and preterm porting an association between library/oralhealth/. Accessed June 22, 2006. 2. William Hunter. Quoted by: OReilly PG, birth/low birth weight, captured two diseases or conditions and Claffey NM. A history of oral sepsis as a cause the attention of the dental pro- those indicating a causal rela- of disease. Periodontology 2000 2000;23:13-8. 3. Thodden van Velzen SK, Abraham-Inpijn fession. In some sense, this can tionship, so that the informa- L, Moorer WR. Plaque and systemic disease: a be construed as a return to the tion can be interpreted accu- reappraisal of the focal infection concept. J Clin Periodontol 1984;11(4):209-20. theory of focal infection. rately. Although oral 4. Newman HN. Focal infection. J Dent Res However, the response of the microorganisms from various 1996;75(12):1912-9. 5. Pallasch TJ, Wahl MJ. The focal infection dental and medical professions sites potentially could be asso- theory: appraisal and reappraisal. J Calif this time was considerably more ciated with systemic disease, Dent Assoc 2000;28(3):194-200. 6. Miller WD. The human mouth as a focus measured than that in the early the articles in this supplement of infection. The Dental Cosmos part of the 20th century. focus on the connection between 1891;33(9):689-713. 7. Hunter W. Oral sepsis as a cause of dis- This is likely a result of sev- dental plaque and periodontal ease. Br Med J 1900;1:215-6. eral factors: the greater sophis- disease and adverse pregnancy 8. Rosenow EC. Studies of elective localiza- tion: focal infection with special reference to tication in methods of scientific outcomes, cardiovascular dis- oral sepsis. J Dent Res 1919;1(3):205-67. investigation and statistical ease, bacterial pneumonia and 9. Taubes G. Epidemiology faces its limits. Science 1995;269(5221):164-9. analysis, including an under- diabetes, as well as the methods
6S JADA, Vol. 137 http://jada.ada.org October 2006
Copyright 2006 American Dental Association. All rights reserved.
Oral and Maxillofacial Surgery Clinics, Volume 15, Issue 1, Pages 1-166 (February 2003), Current Concepts in The Management of Maxillofacial Infections