Questionable Guidelines

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The German Society of Periodontology has initiated a process of developing national guidelines for the treatment of periodontal diseases. The organization claims that they would meet the highest level of evidence (so-called, in Germany, S3 guidelines). A first “consensus report” on the “administration of systemic antibiotics during non-surgical periodontal therapy” has been published in Clinical Oral Investigations by Pretzl et al. (2018).

The article may be influential as it deals with a highly controversial issue. Unfortunately, it does not meet current standards for meta-reviews and contains errors which may render its rather vague and questionable statements even more futile.

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Prediabetics, Subgingival Scaling and the Regression Towards the Mean

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There is still controversy about the meaningfulness of HbA1c reduction in diabetics upon non-surgical periodontal therapy. One may get the impression that the number of systematic reviews (SR) on the issue surpasses the number of quality randomized clinical trials (RCT). The most current update by the Cochrane Collaboration (Simpson et al. 2015) had concluded that,

There is low quality evidence that the treatment of periodontal disease by SRP [scaling and root planing] does improve glycaemic control in people with diabetes, with a me an percentage reduction in HbA1c of 0.29% at 3-4 months; however, there is insufficient evidence to demonstrate that this is maintained after 4 months.

I will stick to that statement although I am fully aware that attempts are being made by representatives of our profession of considering rather systematic reviews of SRs as if that would lead to other research outcomes. For still interested readers, I have reported and discussed the issue in numerous blog posts, see e.g. here, here and here.

Treating all kinds of systemic ailments by proper scaling and root planing has been an illusion of certain periodontists for some time. As a healthy antidot, one should carefully read an interview with Jan Lindhe, published some time ago, where he warned us:

I think that the dentist’s area is pretty well described – it’s intraoral and also maxillofacial in a sense but the dentist shouldn’t be a pseudo-doctor for all types of disorders. (Emphasis added.)

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Gross Picture

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EFP Webpage – under faire use.

As a periodontist who knows about the numerous barriers we face when talking about possibilities of smoking cessation as part of periodontal treatment I have always  expressed empathy even when mentioning serious consequences of Smoking, certainly not discrimination. Currently, dentists are not really educated for that task. It is hoped that this might change in future curricula but I’m not sure.

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Update On the Global Burden of Severe Periodontitis

UPDATE below.

In a previous post, I had questioned how reliable Global Burden of Disease (GBD) estimates of severe periodontitis actually are. The reason was a recent editorial by Kocher and Holtreter (2017) who had asked, “Is the prevalence of periodontitis declining or not?” In a paper by Kassebaum et al. (2014), severe periodontitis had been identified as the 6th most prevalent disease worldwide with 11.2% (743 million) cases in 2010; while in a later paper by the same authors (Kassebaum et al. 2017) an estimate of 7.4% (538 million) in 2015 was published. Case definitions had not changed but maybe the data base has grown?

Prevalence (even incidence) data by Kassebaum et al. (2014, 2017) have been widely discussed, and a questionable measure, disability-adjusted life years (DALY), criticized, as it adopts disability weights which are, in case of severe periodontitis, very low as compared to serious diseases and conditions.

I had contacted Dr. Kassebaum at the University of Washington in Seattle and received meanwhile a kind response. He provided me with a link to the GBD database. Below is displayed the age-standardized prevalence of severe periodontitis in 2016.

Severe Periodontitis Age Standardized 2016

Denmark and Kenya lead with more than 20% age-standardized prevalence.

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