The Literature That Shaped Modern Periodontology (IV)

Bruce Pihlstrom’s account on the occasion of AAP’s centennial, which is published in the recent issue of Journal of Periodontology, is sober and very honest. He had been asked to write about the literature on treatment of periodontitis with a focus on bacterial removal and proper home and professional care. Of course, that is what matters. Within Dentistry, and beginning with Sigurd Ramfjord in Ann Arbor and Jan Lindhe in Gothenburg, periodontists have always been frontrunners in the conduction of randomized clinical trials, and what can be achieved by removal of bacteria and making sure that recolonization is under control has a firm basis.

Pihlstrom writes,

“When the results of trials that showed the efficacy of ‘non-surgical’ periodontal therapy were first published or presented at periodontology meetings, many suggested that the trials were flawed or that the investigators did not know how to properly trate periodontal disease with whatever treatment happened to be favored by critics of the studies. As various groups of academic and private practice periodontists published similar findings from around the world, it was confirmed that both ‘surgical’ and ‘non-surgical’ therapy were efficacious. Use of surgical flap procedures may provide better visual and mechanical access to the root surface and allow approaches to regenerate the attachment apparatus. However, accumulated scientific evidence clearly showed that removal of deposits from the root surface, effective personal oral hygiene, and regular professional periodontal maintenance were the critical foundation of periodontal therapy.”

If it is so that we can achieve most if not, say, 80% of what is achievable by not-surgical periodontal therapy, and if it is so that contemporary clinical studies have large attenuated our enthusiasm as regards what can be achieved by regenerative therapy, be it GTR or Emdogain, why is there not more education in proper non-surgical periodontal therapy provided? All techniques, also non-surgical periodontal treatment, have been refined in recent years. That, based on old studies of the 1970s and 1980s when scaling/root planing was compared with surgical periodontal therapy, minimally invasive flap designs at single-rooted teeth, such as those recently described by Cortellini in a review paper, are automatically superior to scaling and root planing only, is not granted. It’s about access, and if I can get access, I would bet that there will be no difference in outcome regardless of Emdogain was applied or not.

It’s about technical skills, too. I am afraid that certain periodontal scientists, who would find it hard to identify the cutting edge of a curet, have not done us a favor when advocating systemic antibiotics in order to enhance scaling results or reduce treatment need for periodontal surgery. That must be regarded sloppy dentistry. That one may expect transiently more attachment gain when administering metronidazol with or without amoxicillin does not mean that the anatomical defect, be it an infrabony lesion or  an involved furcation, won’t disappear. Antibiotic resistance is a reality, we have again been alerted about the upcoming threat couple of days ago. Except very rare cases, periodontitis must not be treated with antibiotics. It is not a specific infection, it’s a biofilm disease. It is amazing that the principles of not using antibiotics in the treatment of biofilm diseases had been mentioned in an early review article by late Sig Socransky and Anne Haffajee who later eagerly studied the effects of using adjunct antibiotics.

I was positively surprised when recently coming across of similar sentiments as regards non-surgical periodontal therapy from, I suppose, older colleagues in the AAP forum. They obviously know, as I do, what can be achieved when indications are strictly applied. The new generation of periodontists have been mainly confused with so many ephemeral innovations in the last couple of decades. If it is true that that confusion was company-driven in the 1990, now, I am afraid, it is driven by eager scientists who can show, after having properly determined the minimum sample size, “significant” results which are usually clinically irrelevant (but that is hardly mentioned in the paper, getting it published having been the only aim for the exercise).

I have taught clinical Periodontology to under- and postgraduates, dental hygienist students and dental assistants for  more than three decades. The most reasonable but least invasive procedure, i.e., non-surgical treatment and flap surgery in areas of access problems (which is generally well tolerated), is usually recommended first. Proper furcation treatment includes, of course, often resective measures. I was disturbed when reading in the AAP forum that teeth are nowadays extracted at an early stage of periodontal disease in order to place implants. Well, that strategy will backfire soon, too, I am afraid.

2 May 2014 @ 3:25 pm.

Last modified May 2, 2014.

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