I have written this letter: "We read with great interest the study by Keklikkiran et al. showing that patients with NAFLD who brushed their teeth less than once daily had a notably higher prevalence of liver stiffness measurement values equal to or above 12 kPa, a key indicator of hepatic cirrhosis. Furthermore, the authors discovered an independent association between less frequent toothbrushing and a transient elastography (TE)-established diagnosis of cirrhosis in NAFLD. Given the increasing burden of NAFLD, cirrhosis has become a serious public health problem. Keklikkiran et al. be commended for their findings as, in our opinion, they could reveal toothbrushing as a simple yet effective for reversing NAFLD-related cirrhosis. Indeed, recent studies have challenged the traditional notion that cirrhosis is unalterable and permanent. In this context, Pose et al.7 have demonstrated that 1.4% of liver transplant candidates diagnosed with NAFLD or cryptogenic cirrhosis can be removed from the waiting list due to notable clinical improvements. Considering these findings, and based on the research by Keklikkiran et al., we also suggest a thorough examination of toothbrushing frequency from NAFLD patients who experience cirrhosis recompensation and are subsequently delisted. Comparing these results with patients who remain listed may help determine if toothbrushing – as a daily means to maintain oral health by cleaning out the food debris, reduce microorganisms and inflammation - may promote recompensation while awaiting a transplant. In a separate investigation, Chen and colleagues [4] found a positive correlation between tooth loss and the risk of liver cirrhosis. Interestingly, in another recent paper, the authors found that the progression of NASH could be potentially tempered through regular oral health care liver stiffness measurement. In addition, LSM through TE had a significant correlation with an increase in specific periodontal parameters such as pocket-probing-depths and bleeding-on-probing. Consequently, hepatologists should emphasize to their patients the significance of periodic dental check-ups. In summary, the findings by Keklikkiran et al. provide a new outlook onto the role of oral health into the natural progression of end-stage liver disease and shed light on novel research avenues on toothbrushing for promoting reversal of NAFLD-related cirrhosis. To fully comprehend the complex interplay between oral health and cirrhosis, more studies are needed, especially those utilizing the new nomenclature framework (Metabolic dysfunction associated steatotic liver disease or MASLD) set to replace the current NAFLD definition". Do you have any comments or additions?

Enzo Emanuele
The following are the creative, novel ideas generated by AhaApple using AI + brainstorming techniques + innovative techniques simultaneously:
  1. NAFLD: Your letter already demonstrates depth of understanding, but perhaps you can mention more about NAFLD's increasing prevalence globally and its contribution to health disparities in different regions.
  2. Toothbrushing: Suggesting innovative methods (like smart toothbrushes) to monitor toothbrushing behavior in patients could make the letter more engaging.
  3. Liver stiffness: Exploring more on how liver stiffness is measured and its implications could provide more clarity to the readers and make the findings of Keklikkiran et al. more comprehensive.
  4. Cirrhosis: It might be beneficial to add some insights into the treatments available and those under research in the field of liver cirrhosis.
  5. Elastography (TE): You can propose potential improvements in transient elastography technology, or suggest the application of AI to detect liver disease in its early stage.
  6. Public Health: Don't forget to mention the socioeconomic impacts of NAFLD and its related diseases, as well as the importance of public health education and promotion plans.
  7. Transplant: Highlight the need for exploring other non-invasive treatments and preventive strategies alongside the existing methods like transplantation.
  8. Recompensation: Suggesting some researches on recompensation mechanism or any link with other health practices could make the letter more detailed.
  9. Tooth loss: Explaining any correlation of tooth loss with other systemic diseases might be an interesting addition.
  10. Pocket-probing-depths: Including references to studies examining the relationship between specific periodontal parameters and liver health could be beneficial.
  11. Periodic dental check-ups: Emphasize more on the need of having multi-disciplinary coordinated care involving both hepatologists and dentists.
  12. NASH: Elaborate on the progression and the economic burden of NASH, and how oral health care can help in tempering this.
  13. Oral health care: Expanding discussions on the potential of oral health care in improving overall health and wellbeing could be a great addition.
  14. End-stage liver disease: Providing insights into the management of end-stage liver disease and the role of oral health in palliative care settings could be reasoned.
  15. Novel research avenues: Highlight some existing research gaps and suggest potential research areas in the connection between oral health and NAFLD-related cirrhosis.
  16. Metabolic dysfunction: Showcasing the complexity of metabolic dysfunctions in liver disease, giving insights on this new nomenclature (MASLD) could be an interesting addition.
  17. Hepatic cirrhosis: Comment on the innovative methods for early detection of hepatic cirrhosis, underscoring the role of lifestyle modifications like regular oral care.
  18. Inflammation: Linking the process of inflammation to the progression of liver disease and discussing the role of toothbrushing in minimizing inflammation may add more depth.
  19. Microorganisms: Discuss the potential role of oral microbiota in liver health, drawing a line of connection with Keklikkiran et al.'s findings.
  20. Steatotic liver disease: Proposing some anticipative measures or medication to prevent steatotic liver disease could be an important addition.