Some Remarks on “100 Years of Progress in Periodontal Medicine” (II) – Diabetes Mellitus

Diabetes

ISTOCK/MTHIPSORN under fair use.

That periodontitis and diabetes mellitus are related is known for more than 100 years. While Beck et al. (2019), in their contribution to the JDR Centennial Series on 100 Years of Progress in Periodontal Medicine, start out with a paper by Williams and Mahan (1960), which is mentioned as the first landmark paper (allegedly the first study showing that periodontal therapy reduces insulin requirement; but this study had only shown that removing all teeth with advanced decay improved glycemic control), the latter authors quote a booklet by Otto Georg Grunert of 1899 a patient guidebook for diabetics: Ueber Krankheitserscheinungen in der Mundhöhle beim Diabetes: Therapeutische Winke für Diabetiker. In particular the medical profession had known about the link of diabetes mellitus and oral disease for long.

Further landmark, or “milestone”, papers in Beck et al.’s list on the diabetes-periodontitis relationship appeared around 1996, when late Professor Robert J. Genco, for the first time, had used a slide with the message, Floss or Die! on the occasion of the annual meeting of the American Academy of Periodontology in New Orleans. Some of these studies indeed sparked the idea that it would be possible to reduce HbA1c, the marker of diabetic control, by proper periodontal treatment of diabetic patients.

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Getting it All Wrong

Stage I

Teaching Perio to undergraduates has become tricky after former delegates of the 2017 World Workshop on Classification of Periodontal Diseases etc. had started to explain, in more detail, what they actually had in mind. Professor Mariano Sanz has undertaken the task to outline, in about 10 short video clips, Staging & Grading of periodontitis and eventually, in the very last clip, he got the opportunity to present some clinical examples.

The videos can be accessed on the EFP webpage as well as on Youtube.

 

I have presented the series of videos to 7th semester students this week, and it was only the second time that I had watched the entire series of video clips. Even before, I’d got some “wait a minute” moments. Today, I want to scrutinize the clinical examples more carefully [1].

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Some Remarks on “100 Years of Progress in Periodontal Medicine” (I) – Cardiovascular

Beck 2019

In its “Centennial Series”, an article celebrating Periodontal Medicine appears in next month’s issue in the Journal of Dental Research. The authors James Beck, Panos Papapanou, K.H. Philips and late Steven Offenbacher scrutinize a number of so-called landmark, or “milestone”, studies regarding three pathologic conditions, cardiovascular disease, diabetes mellitus, and adverse pregnancy outcomes. As in every opinion piece, one needs careful reading in order to identify the authors’ bias [1].

Cardiovascular disease

The authors recapitulate the timeline beginning with W.D. Miller’s dental focal hypothesis of 1891. (When writing, I couldn’t get full access to the Lancet article of 1891 to which Beck et al. originally refer.)

They then turn to the stunning (then) observation by Finnish authors Mattila et al. (1989) who adopted a “dental index” of caries, marginal and apical periodontitis, and pericoronitis in a case-control study of hospital admitted patients with recent myocardial infarction and matched controls from official records inhabitants of Helsinki. These authors had set up a logistic regression model adjusted for traditional risks, in particular smoking (former and current smokers) and identified the “dental index” (as well as smoking and, negatively, HDL cholesterol) being statistically significantly associated with myocardial infarction (Odds ratio 1.2586, 95% confidence interval 1.1503; 1.3771, my calculation based on given coefficient and standard error estimates). In two subpopulations, medians of the dental index were 4 and 6. So, the observed odds ratio for increase of 1 score in the index (1.2586) must in fact be considered substantial. This was a single center, low quality (as of current standards) case-control study which had to be confirmed in larger observational and ultimately interventional studies.

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A Remarkable Strategy

In general, services by GoogleScholar are beneficial. I have written about that and possible abuse here. If someone creates a GoogleScholar account, some citation metrics are calculated automatically. If your name is common, as is mine, the author is well-advised to clear the list from articles which are not his. As also quotations in books and dissertations are considered, GoogleScholar’s h-index is usually higher than that calculated by, e.g., Web of Science which considers only a core collection of journals.  But that is basically not a bad thing. After all, a quotation is a quotation.

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Our Thought Leaders’ Dilemma

In a previous post, I had expressed my concerns about day-to-day applicability of the new Staging and Grading system of periodontitis. In particular teaching it to undergraduate students has turned out to be difficult and short-time experience with it had already led to my decision: Here at UTK/IKO we won’t do attachment level measurements (apparently one main prerequisite in the new system) on a routine basis in order to distinguish initial (formerly mild) from moderate periodontitis and severe from very severe disease, save diagnosis of periodontally healthy patients.

How this may actually work has been shown in the recent Fédération Dentaire Internationale (FDI) chairside guide which uses very similar definitions but without systematically recorded clinical attachment levels, see below. When it comes to grading, there are differences as to the current EFP/AAP suggestions, but not fundamental.

FDI

Yesterday, Tonetti and Sanz have published decision making “algorithms” for clinical practice and education which once more prove that EFP/AAP suggestions are academically sound but extremely hard to implement in a clinical setting.

Here come the seven decision making flow charts which will be printed soon in the Journal of Clinical Periodontology.

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