2060
LETTERS TO THE EDITOR
allows us to identify only associations between advance care planning (ACP) and aspects of end-of-life care. We state in our paper, “the observational study design meant that only associations could be reported; that ACP causes changes in healthcare use cannot be concluded.” It is possible, even likely, that certain people are more apt to engage in ACP and also more likely to pursue hospice, as Dr. Finucane proposes. However, it is also likely that, in some cases, ACP influences end-of-life care; we write that our data “suggest” this possibility, although they do not prove it. We acknowledge that a prospective randomized controlled trial could be helpful but would be time consuming and expensive to perform on such a large scale as our study. Kara E. Bischoff, MD Department of Medicine, University of California at San Francisco, Moffitt Hospital, San Francisco, California
ACKNOWLEDGMENTS Conflict of Interest: None. Author Contribution: Dr. Bischoff designed and wrote the letter in full. Sponsor’s Role: None.
PERIODONTITIS, EDENTULISM, AND DEMENTIA To the Editor: Stewart and colleagues demonstrate that “periodontitis may be a risk factor for cognitive decline,”1 but they also refer to a prospective relationship between dementia and edentulism 12 years previously. Wouldn’t it be right to think that these individuals with dementia, having been free of dentition for 12 years, would also have been free of periodontitis for that interval? This seems to be indirect evidence that recent or ongoing local inflammation, at least of the structures surrounding the teeth, is not strongly causally related to dementia. Thomas E. Finucane, MD Johns Hopkins Bayview Medical Center, Baltimore, Maryland
NOVEMBER 2013–VOL. 61, NO. 11
JAGS
RESPONSE TO THOMAS FINUCANE To the Editor: The authors thank Dr. Finucane for his letter raising the question regarding the association between edentulism and dementia that was referenced in our article.1 Dr. Finucane’s question refers specifically to the Nun Study cited in our Introduction, one of the few studies to investigate prospectively the association between dementia and measures of oral health. A study of 144 nuns in Milwaukee found that tooth loss was associated with prevalence and incidence of dementia over 12 years of followup.2 The use of the term “edentulism” in our text could be cause for confusion. In the Nun Study, partial (some tooth loss but some teeth remaining) and complete (complete tooth loss) edentulism were combined and referred to collectively in our text as edentulism. Although space limitations prevent a full review of the findings reported in the Nun Study, it concluded that partial edentulism was significantly associated with prevalent and incident dementia. Complete edentulism was investigated only in a cross-sectional analysis and was found to be not significantly associated with prevalent dementia at baseline, although a suggestive finding was reported for nuns without the apolipoprotein E4 allele. Incident disease was investigated using only a grouping of individuals in which those with complete edentulism were combined with those with one to nine remaining teeth, preventing assessment of complete edentulism alone. As was noted, the Nun Study should be interpreted with caution, because causes of tooth loss other than periodontal disease are possible. Moreover, these data do not support ascribing causality to these findings. Robert Stewart, MD Section of Epidemiology, Institute of Psychiatry, King’s College London, London, UK Robert Weyant, DMD, DrPH Department of Dental Public Health, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania Anne Newman, MD, MPH Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
ACKNOWLEDGMENTS ACKNOWLEDGMENTS Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the author and has determined that the author has no financial or any other kind of personal conflicts with this paper. Author Contributions: TF is responsible for the entire content of this paper. Sponsor’s Role: Not applicable.
REFERENCE 1. Stewart R, Weyant RJ, Garcia ME, et al. Adverse oral health and cognitive decline: The Health, Aging and Body Composition Study. J Am Geriatr Soc 2013;61:177–184.
Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: All authors contributed to this paper. Sponsor’s Role: None.
REFERENCES 1. Stewart R, Weyant RJ, Garcia ME et al. Adverse oral health and cognitive decline: The Health, Aging and Body Composition Study. J Am Geriatr Soc 2013;61:177–184. 2. Stein PS, Desrosiers M, Donegan SJ et al. Tooth loss, dementia and neuropathology in the Nun Study. J Am Dent Assoc 2007;138:1314–1322.
LETTERS TO THE EDITOR
allows us to identify only associations between advance care planning (ACP) and aspects of end-of-life care. We state in our paper, “the observational study design meant that only associations could be reported; that ACP causes changes in healthcare use cannot be concluded.” It is possible, even likely, that certain people are more apt to engage in ACP and also more likely to pursue hospice, as Dr. Finucane proposes. However, it is also likely that, in some cases, ACP influences end-of-life care; we write that our data “suggest” this possibility, although they do not prove it. We acknowledge that a prospective randomized controlled trial could be helpful but would be time consuming and expensive to perform on such a large scale as our study. Kara E. Bischoff, MD Department of Medicine, University of California at San Francisco, Moffitt Hospital, San Francisco, California
ACKNOWLEDGMENTS Conflict of Interest: None. Author Contribution: Dr. Bischoff designed and wrote the letter in full. Sponsor’s Role: None.
PERIODONTITIS, EDENTULISM, AND DEMENTIA To the Editor: Stewart and colleagues demonstrate that “periodontitis may be a risk factor for cognitive decline,”1 but they also refer to a prospective relationship between dementia and edentulism 12 years previously. Wouldn’t it be right to think that these individuals with dementia, having been free of dentition for 12 years, would also have been free of periodontitis for that interval? This seems to be indirect evidence that recent or ongoing local inflammation, at least of the structures surrounding the teeth, is not strongly causally related to dementia. Thomas E. Finucane, MD Johns Hopkins Bayview Medical Center, Baltimore, Maryland
NOVEMBER 2013–VOL. 61, NO. 11
JAGS
RESPONSE TO THOMAS FINUCANE To the Editor: The authors thank Dr. Finucane for his letter raising the question regarding the association between edentulism and dementia that was referenced in our article.1 Dr. Finucane’s question refers specifically to the Nun Study cited in our Introduction, one of the few studies to investigate prospectively the association between dementia and measures of oral health. A study of 144 nuns in Milwaukee found that tooth loss was associated with prevalence and incidence of dementia over 12 years of followup.2 The use of the term “edentulism” in our text could be cause for confusion. In the Nun Study, partial (some tooth loss but some teeth remaining) and complete (complete tooth loss) edentulism were combined and referred to collectively in our text as edentulism. Although space limitations prevent a full review of the findings reported in the Nun Study, it concluded that partial edentulism was significantly associated with prevalent and incident dementia. Complete edentulism was investigated only in a cross-sectional analysis and was found to be not significantly associated with prevalent dementia at baseline, although a suggestive finding was reported for nuns without the apolipoprotein E4 allele. Incident disease was investigated using only a grouping of individuals in which those with complete edentulism were combined with those with one to nine remaining teeth, preventing assessment of complete edentulism alone. As was noted, the Nun Study should be interpreted with caution, because causes of tooth loss other than periodontal disease are possible. Moreover, these data do not support ascribing causality to these findings. Robert Stewart, MD Section of Epidemiology, Institute of Psychiatry, King’s College London, London, UK Robert Weyant, DMD, DrPH Department of Dental Public Health, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania Anne Newman, MD, MPH Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
ACKNOWLEDGMENTS ACKNOWLEDGMENTS Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the author and has determined that the author has no financial or any other kind of personal conflicts with this paper. Author Contributions: TF is responsible for the entire content of this paper. Sponsor’s Role: Not applicable.
REFERENCE 1. Stewart R, Weyant RJ, Garcia ME, et al. Adverse oral health and cognitive decline: The Health, Aging and Body Composition Study. J Am Geriatr Soc 2013;61:177–184.
Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: All authors contributed to this paper. Sponsor’s Role: None.
REFERENCES 1. Stewart R, Weyant RJ, Garcia ME et al. Adverse oral health and cognitive decline: The Health, Aging and Body Composition Study. J Am Geriatr Soc 2013;61:177–184. 2. Stein PS, Desrosiers M, Donegan SJ et al. Tooth loss, dementia and neuropathology in the Nun Study. J Am Dent Assoc 2007;138:1314–1322.
