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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Periodontal Therapy For the Management of Cardiovascular Disease in Patients With Chronic Periodontitis

EFP_WHF

The issue mentioned in the title was dealt with in a systematic review of the Cochrane Collaboration which was published 3 1/2 years ago. It confirmed that, since the publication of the PAVE pilot study in 2009, no further evidence had emerged. The authors of the Cochrane review concluded,

We found very low quality evidence that was insufficient to support or refute whether periodontal therapy can prevent the recurrence of CVD in the long term in patients with chronic periodontitis. No evidence on primary prevention was found.

Possible systemic effects of periodontal treatment had been claimed for a very long time, and lack of evidence, or evidence for their clinical irrelevance, had never been accepted by many colleagues, indeed.

The most recent attempt of reviving the largely  lapsed interest by most of our medical colleagues in the Perio-Systemic link, in particular its cardiovascular branch, was launched earlier this week when a delegation of the European Federation of Periodontology (EFP) met colleagues of the World Heart Federation (WHF) in Madrid. The aim of the workshop was to “explore the links between periodontal disease and cardiovascular disease and draw up a series of recommendations.”

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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 leaders 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

amoxicillin

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

blutzucker

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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