Editor's summary

In the year 2000 I suggested somewhat tongue-in-cheek to a young colleague who asked what I thought might be the best route to a successful career in dentistry in the twenty-first century that periodontology offered the widest scope. When challenged further I opined that before very much longer periodontal disease would be linked, primarily through the mediation of inflammation, to most other diseases, making periodontologists the centre of the dental and medical world.

With expanding research in this field, periodontology is now being investigated in its possible links to pregnancy, heart disease, diabetes and rheumatic conditions to mention just four areas. This current research paper adds a further possibility, that of a link between periodontal disease and osteoporosis through the connection of tooth loss.

In concluding that there was a significant correlation between tooth loss and osteoporosis for the 333 individuals included in the study, the authors quite rightly then speculate on the possible further association with inflammatory periodontal disease. Of course there are other local and systemic factors that exert an influence on tooth loss and more research is required. However, posing the possibility of a link opens up wider speculation on the potential role of cytokines so intimately implicated in the various connections alluded to above.

It seems increasingly intuitive that investigation into the part played by inflammation in a variety of conditions that afflict mankind will sooner or later bring forth significant results which will enable greater understanding and, hopefully, improved preventive and treatment possibilities. We have some way to go and, as these authors point out, there is much soul searching and redoubling of effort to get there. But get there we will and this piece of research adds a further important piece to the evolving jigsaw.

The full paper can be accessed from the BDJ website ( www.bdj.co.uk ), under 'Research' in the table of contents for Volume 214 issue 4.

Stephen Hancocks

Editor-in-Chief

Author questions and answers

1. Why did you undertake this research?

The existing literature gives mixed messages about the relationship between osteoporosis and oral health, particularly periodontal disease, so we wanted to improve knowledge about this. Some of the authors also have a long-standing interest in how dentists can identify patients at high risk of having undiagnosed osteoporosis using dental radiographs, so have spent time talking to sufferers and have recognised their interest in how the disease affects their teeth.

2. What would you like to do next in this area to follow on from this work?

The pathological process that may link osteoporosis and premature tooth loss is poorly understood. It has been suggested that this may be due to an association between periodontal disease and osteoporosis. In osteoporotic patients there may be an increased circulation of inflammatory cytokines, predisposing to periodontal ligament breakdown. Furthermore bone of low mineral density may be less resistant to the inflammatory changes in chronic periodontitis. Thus there may be accelerated breakdown of alveolar bone in these individuals. The current study was cross-sectional, so we would like to go back to the patients as part of a longitudinal study to assess their periodontal status after a period of some years. In the future, it would also be worthwhile looking at responses to prevention and treatment compared with a control group. These patients are usually highly motivated and may respond well to prevention.

Commentary

Increasingly in dentistry we are considering more and more a patient's medical history, the overall health of our patients and the impact that that can have on their dental disease status.

This interesting paper considers whether there is a connection between osteoporosis and tooth loss as there is conflicting evidence in the literature with respect to this.

The research team in Manchester has a history of considering osteoporosis specifically and its relationship to dental disease; and also whether dental radiographs might be used in earlier diagnosis of osteoporosis, which is of course a very distressing condition. The paper concluded that there was a significant correlation between tooth loss and osteoporosis for the 333 individuals included in the study. It very honestly also points out that there may well be local or other systemic factors that exert a greater influence on tooth loss and that clearly more research is required. Based on the evidence, the researchers suggest that patients should be informed if they are osteoporotic that they may be at a greater risk of losing molar teeth in the future. They also suggest that these patients should be reviewed more frequently because their risk is higher and their oral hygiene and preventive measures should be targeted specifically. This seems reasonable and intuitively seems correct, based on the evidence and the findings of this study and very much fits with the targeting of preventive treatments to high priority groups.

It is important to note that much more research is required. Very often studies of this type raise more questions than provide clear answers, which is the very nature of clinical research itself. I, however, suspect that we will achieve a greater understanding of the oral impact of osteoporosis in the coming years.

1. Professor of Restorative Dentistry / Director of Student Education Leeds Dental Institute