Beyond the confines of the vermillion border and pillar of fauces, evidence is mounting of the importance of oral health and its impact on the human body, and I am sure medical practitioners will soon implement words such as, 'periodontal disease', into their vocabulary.
However, it seems surgeons would also benefit from taking note of this evidence.
What's the latest evidence? A study of cancer patients receiving oral care pre-op
The British Journal of Surgery, a peer-reviewed journal, recently published a study from Japan concluding that cancer patients who received oral care before cancer surgery had significantly reduced post-operative complications (Ishimaru et al. 2018).
The retrospective study looked at data from 509,179 cancer patients, out of which 81,632 had received pre-operative oral care.
Analysis found rates of post-operative pneumonia and all-cause 30-day mortality were significantly reduced when compared to the group who did not receive pre-operative oral care.
Limitations of this study
Alas, under the microscope the study reveals limitations that will ultimately hinder its acceptance into routine clinical practice.
1. What is pre-operative oral care?
- The study did not give details on the oral care that cancer patients received.
- Factors to consider include whether it was a GDP or specialist providing treatment, grade of the dentist and the type of treatment given. Does it even matter? We don't know
2. What about other post-operative complications?
- Complications such as wound infection, massive haemorrhage or sepsis were not mentioned in the study.
- Therefore, the conclusion '…cancer patients who have oral care before cancer surgery have significantly reduced postoperative complications' is misleading as pneumonia was the only complication discussed.
3. Do significant results equate to clinical relevance?
- With evidence-based practice there is a tendency to conflate statistical significance with clinical relevance. This study analysed data retrospectively, and despite the statistical significance of the results, residual confounding may still be present.
- To extrapolate results with confidence, a well-designed large scale prospective randomised control trial (RCT) would need to be conducted.
- With RCTs a common hurdle is clinical equipoise but given the lack of evidence supporting oral care prior to cancer surgery, true equipoise can be achieved.
The case for holistic patient care
Despite limitations, the study raised important points for me as a dentist striving for holistic patient care:1. Communication
2. Need RCTs!
- Whether it is declaring patients dentally fit for cardiac surgery or chemotherapy, dentists play an essential role in patient care for a range of conditions.
- We must encourage our medical colleagues to seek out dental opinions prior to treatment if they have concerns about their patient's oral health.
- Conversely, the medically complex patient is becoming more common, and we must not hesitate to liaise with specialists when we are in doubt.
- Although guidelines are in place for situations which may require antibiotic prophylaxis or alteration of medications, there is no harm in simply picking up the phone or writing a letter to the GP or hospital just to double check.
3. Multi-disciplinary team
- As alluded to above, we need more RCTs to clarify the impact of oral health on the human body.
- There are already studies suggesting a link between poor oral health and post-operative pneumonia. Perhaps with further investigation we could elucidate the relationship and help mitigate this and maybe even other complications.
- The enhanced recovery after surgery (ERAS) protocol is an evidence-based care pathway designed to optimise recovery after major surgery.
- If poor oral health is found to be a factor in recovery, it could see dentists becoming a part of the multi-disciplinary team for all surgical patients, not just head and neck cancer patients.
- Whether this care is provided in hospitals under restorative, special care or GDPs is a separate discussion, and funding in the current state of the NHS remains to be seen.
In summary, this study provides a timely reminder that the role of the dentist is becoming ever more important in the treatment of patients across healthcare.
The evidence needs bolstering, but dentists must be aware of their increasing responsibility in the holistic management of many more diseases, and we will need to foster stronger relations with GPs and hospitals.
Jasdeep Brar, Foundation Dentist
Developing your career: support for dentists
BDA membership offers you advice and support to help you succeed in your career as a dentist. You get access to the world's leading dental journals, including the BDJ and BDJ in Practice, and our eLibrary, featuring over 300 eBooks.
Read the latest news and opinions via our blogs. If you'd like to contribute to our blogs new submissions are always welcome, please get in touch.