General Health

relation of

and

Christoph Benz

prologueprologue

medicine is an “art of probabilities,”at best, a “science of uncertainty”

uncertainty

Sir William Osler1849-1919

„measurement has over promisedaugust 2015

Gene Glass1940

and under delivered“

prologueprologue

mechanistic evidencethere is a physiological or (micro)biological

explanation how condition A maypathomechanism

empirical evidenceevidence in patients that proofs there is a

dependance of condition B on condition Agold standard: RCT

NCD evidence

lead to condition B

prologueprologue

primary outcome

surrogate outcomes

the most important outcome,

freedom from myocardial infarction and survival a real clinical endpoint

measures of an effect that may correlate witha real clinical endpoint, but not necessarily

cholesterol level probing depth, BOP

tooth lossendocarditis

bacteremia

outcome measures

prologueprologue

ethical considerationsprolongation of a study

difficulty to standardize study-groupslarge group sizes

why surrogate?

prologueprologue

because of the multitude of individualinfluences the same cause maylead to very different effects

periodontitis is a risk factor

one cause one effect?

the clinical relevance is dependent on acomplex interplay from genetics to behavior

what we knowwhat we know

Disease periodontitisasriskfactor

association patho-mechanism

Intervention:surrogate

Intervention:primary

Endocarditis ++ yes yes yes no

RecurrentPneumonia

++ yes yes n.a. yes

CardiovascularDisease

+ yes yes yes no

ChronicKidneydisease

+ yes yes n.a. yes

DiabetesMellitus + yes yes yes no

Cancer yes yes no no

COPD yes yes n.a. yes

Dementia yes yes no no

Gastritis yes yes n.a. yes

RheumatoidArthritis

yes yes no no

periodontitis

what we knowwhat we know one example

cardiovascular disease

periopathogens in atherosclerotic vessel wallsHaraszthy et al. 2000, 2001, Mastragelopoulos

et al. 2002, Desvarieux et al. 2006

animal model: periopathogensOffenbacher et al. 1999, Li et al. 2002

initiate atherosclerotic plaques

endothelial dysfunction reversedTonetti et al. 2007

by periodontal therapy

what we knowwhat we know

problems …

no large scale industrial orpharmaceutical interests that lead

little interest of general medicineto the funding of expensive studies

and politics in dental topics

dental science

what we knowwhat we know

we have found …, but the evidence is not

often because they …feel insecure about their study

want new research-funding

sufficient. Further research is necessary.

classical expression of a scientist …

were obliged by peer reviewers

dental science

what we knowwhat we know

considering periodontitis, we want torecommend preventive measures

what we need are relevant endpoints

because we want to convince …

the insurance-systems to spendmoney on prevention

the patients to spendtheir own money on prevention

underline our recommendationsin the field of general medicine to

What do we want?

the practitionerthe practitioner

what we know

in the mouth

clinical endpoints

what we know

we have observational evidence for

the practitioner

tooth losssevereperiodontitis

inflammation

less …

what we knowwhat we know

The information and

concerning

60

70

80

90

1995 2000 2005 2010 2015

12 years

35-44-years

65-74 years

prevention-baseddental visits [%]

to talk to our patientsis more than enoughevidence we have today

the practitioner

general health?

what we knowwhat we know

Insurance-systems?at least in Germany the highest levels

2 questions …Will we ever reach these levels?

Do we really want insurance money?

of evidence are required

the practitioner

concerninggeneral health?

take hometake home

never hesitate to recommendhigh-class preventive measures

we have all the hard endpoints in dentistryand sufficient evidence in general medicine

relying on the money of our patients

people in the need of carepoor people

leaves at least 2 groups without prevention

(less developed countries)