We read with interest Drs. Andrew and Amy Tanchyk’s letter in response to our article and would like to commend them for their diligence and commitment to the overall health of their patients. Their letter opens up the age-old discussion of how much involvement dentists should have in advising overall and specific health care to their patients. We support the view that dentists should aggressively monitor and be involved in the systemic health of their patients, and we believe it is paramount to successful treatment of all patients.
Fortunately for us, our patients had well-controlled gastrointestinal disease with mainly oral symptoms and signs that responded well to topical steroid therapy. In addition, many of the cases reported in our article were diagnosed in the middle to late 1990s, when many of the latest immune-modifying drugs were not available.
We would like to note that oral symptoms may be the first sign of these serious systemic disorders. An astute dentist should be able to refer such a patient to a competent specialist for appropriate therapy, and then follow up both with the patient and the physician as the course of treatment progresses.
Moreover, the pharmaceutical breakthroughs available to patients with serious systemic disorders are as fast-changing as they are diverse, making it very difficult for the average dentist (and sometimes physicians) to keep up with the latest therapies available for the myriad diseases patients may have. That is one of the reasons why today’s informed patient seeks a specialist’s advice on most of these conditions. The medications that the Drs. Tanchyk mentioned—namely, Enbrel (Immunex Corporation, Thousand Oaks, Calif.), Remicade (Centocor, Horsham, Pa.) and Humira (Abbott Laboratories, Abbott Park, Ill.), all tumor necrosis factor (TNF) antagonists—affect the normal immune response in humans and, as a result, may present with serious side effects, including but not limited to an increase in the risk of developing unusual infections like tuberculosis. Also, there is a risk of increased sinus infections, bronchitis and pneumonia.1–4
Other issues that are being investigated are the risk of lymphoma, congestive heart failure and multiple sclerosis. In fact, Ramos-Casals and colleagues2 report development of autoimmune diseases in patients receiving TNF antagonists. Additionally, there is inconclusive scientific evidence that TNF antagonists improve oral manifestations of autoimmune disease.
We believe dentists should advise patients to seek the latest medical care from their physicians. It would be beyond the scope of dental practice to advocate specific immune suppressive medications for treatment of nondental/nonoral diseases that may or may not have oral manifestations.
A point worth mentioning is that most of the patients the Drs. Tanchyk described as having oral manifestations of serious systemic diseases were either good friends or family members, introducing the possibility of personal bias. It would be interesting to ask the readership if they would feel comfortable, for example, advising patients regarding the latest pharmacotherapy available for severe renal disease or adrenal malfunction, both of which may produce oral manifestations.
In conclusion, we do agree and advocate that dentists should be aware of the systemic health of their patients should communicate with physicians and patients, and should be an integral part of the disease management team. However, we would caution against becoming too involved in promoting specific systemic therapies for multisystem diseases that may or may not produce oral manifestations.
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