What’s Wrong With the Staging And Grading Proposal?

DISCLAIMER. The following is just a brief academic analysis, not outright denial, of the honest efforts by a great number of delegates of the 2017 World Workshop. I have appreciated the interest of readers from around the world in my, well, assumed biased opinion but also had noticed almost silence from much of the publishing scientific community about the proceedings of the Workshop. They still seem to digest (and so do I) what has been published in the two supplements of the Journal of Periodontology and Journal of Clinical Periodontology in June 2018.

I have spent the last couple of months (as most probably colleagues around the world)  revising lectures and handouts and updating my still rather successful German edition of my Perio textbook. It was, of course about the consensus our eminent leader in the European Federation (EFP) and American Academy of Periodontology (AAP) had reached on Staging and Grading periodontitis and numerous other diseases and conditions of the periodontium. As new students have commenced the clinical part of our curriculum here at UiT, I had ample time of discussing the pros and plenty cons of the new system and finally made a decision: we are not going to implement attachment level measurement at six sites per tooth on a routine basis. Maybe some of the suggestions made by Tonetti et al. (2018) but certainly not all.

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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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