Commentary: is tooth loss good or bad for general health?

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Abstract
Abnet et al.1 show that tooth loss is associated with increased risk of mortality from upper gastrointestinal cancer, heart diseases, and stroke. In the last decade, those working in oral health research, especially within periodontology, have shown increasing interest in studying the possible link between oral health and systemic health outcomes. The study by Abnet et al. evidently shows the difficulties and limitations in study design faced by proponents of a causal relationship. It is simple to think of a randomized controlled trial to test the hypothesis of a relationship between oral health status and systemic health outcomes (not surrogate endpoints such as inflammatory cytokine levels): patients with advanced periodontal disease are randomly allocated to two groups in which one receives standard treatment and maintenance care and the other receives no treatment. However, this study design would be considered unethical. Furthermore, differences in treatment outcomes between the two groups, such as episodes of stroke, will take many years to manifest, and it can be assumed that the treatment reduces/reverses the risk generated by periodontal diseases. Consequently, the only practical alternative research data must come from large-scale cohort studies, such as that reported by Abnet et al., or from case–control studies.