Earlier this year, delegates of the European Federation of Periodontology (EFP) and the International Diabetes Federation (IDF) had met in Madrid for a joint workshop on an update of the Perio-Diabetes link. I had reported on the event and some key findings, quickly posted on the EFP web page, here.
Already on and after 24 August 2017, a Consensus Report by the two organizations was prematurely published, and quickly (temporarily) withdrawn, in the EFP’s Journal of Clinical Periodontology and the IDF’s Diabetes Research and Clinical Practice. I had managed to get a print-out of the not-yet edited (and later withdrawn) draft version published on the JCP Accepted Articles page and had noticed that most of the evidence presented was derived of yet-to-be published review articles based on the workshop proceedings.
The final version of the Consensus Report (Sanz et al. 2017, Early View Articles), including guidelines for patients and health professionals dealing with patients suffering from diabetes and periodontal disease, went online this week, but still references to review papers presented on the occasion of the workshop have a 2017 assignment and are not paginated which may make it more difficult for scientists and clinicians outside periodontology or dentistry to locate the final papers.
To be clear, when it comes to keeping our medical collegues, and in particular diabetologists, interested in the very long-known link between periodontitis and metabolic diseases, proving beneficial effects of periodontal treatment on diabetic control is crucial. All was fine as long as numerous published, small-scale, mostly single-center, and often poorly executed, trials apparently showed that thorough subgingival scaling in patients with both periodontitis and diabetes led to an about 0.4% reduction of glycated hemoglobin (HbA1c), at least after three or four months. As that would in effect spare an additional antidiabetic drug, diabetologists stayed interested. Although results in a few trials indicated that the effect was not long-lasting, i.e., no longer discernable after, say, six months.
The above is the conclusion of a recent retrospective evaluation of root-resected molars during a time-span of 30 years in a private practice. I would like to draw attention in particular to the last part of the sentence which is of utmost importance. I shall explain below, what I think is necessary when reporting research findings in an honest way.
When has root resection been reported first?
Root resection, or amputation, is an old story. According to common wisdom, it had been Dr. John N. Farrar from Brooklyn, NY, who had reported first on so-called “radical and heroic treatment” of alveolar abscesses by amputation of roots of teeth , “in order to enable nature to have a better chance for cure.” Dr. Farrar correctly stated that, “if an entire tooth should be extracted from a diseased socket, the treatment might be termed highly radical.” He considered that such a treatment might not only unwise and unnecessary but “absolutely wrong and unscientific [sic].”
It is amazing that, some 130 years ago, reporting couple of cases was considered “science”. The times they are a changin’. Maybe in 100 years our current approach to what is still regarded scholarship and science will be ridiculed as well.
What can be achieved
Root resection or hemisection of furcation-involved molars are still common treatment options based on more rigorous research in the past 45 years. There may be also other indications, endodontic and iatrogenic. Implant dentistry is of course an interesting alternative, and a not so recent case series of patients attending a single private practice by Fugazzotto (2001) from Milton, MA, had shown comparable results regarding successful treatment of either root resection of molars (n=701) or placing implants in molar locations (n=1472) after 15 and more years and 13 years, respectively. Indeed remarkable results, namely success rates of 96.8% for root resected molars and 97% for implants.
After rather devastating negative conclusions made in a systematic review (SR) of the literature regarding the long claimed, possibly causal, relationship between periodontitis and atherosclerotic vascular disease by Lockhart et al. (2012), a highly alerted group of members of our specialty organizations, the Amercian Academy of Periodontology and the European Federation of Periodontology, had hastily organized a joint workshop, in the end of 2012, to fix unwelcome results of a number of large intervention studies by creating new systematic reviews on the Perio-Systemic link. The clear aim was to cement, once and forever, the claim of the number one clinical problem: periodontal disease and general health are closely related.
While the proceedings had been published, open access, in special issues of our main professional journals, the Journal of Clinical Periodontology and the Journal of Periodontology, workshop participants of the EFP presumptuously condensed the 209 pages of the 16, mostly valuable, papers in a nutshell, strangely called Manifesto.
An enthusiastic opinion piece (erroneously designated Systematic Review) has just appeared in the August issue of the prestigious Journal of Clinical Periodontology (Miron et al. 2016). The 16 pages are authored by a remarkable number of 20 authors.
This is certainly not a systematic review as basic PRISMA requirements are not met. Not a single one. So, has this to be regarded just another old fashioned narrative review? I can’t help but when reading the first authors’ unwarranted zeal this may actually be just another brazen commercial. I am afraid that most if not all authors are listed on Straumann’s pay roll, the company which currently markets Emdogain. Thus, the required (for biomedical journals) Conflict of interest and source of funding statement sounds, well, frivolous.
The authors report no conflict of interest for the present review article. No funding was required [sic]/received by any of the co-authors for the present review article.
According to his CV, Dr. Miron alone received 270,500 CHF ($274,246) from Straumann between 2010 and 2015.
As the authors dare to suggest recommendations (called guidelines, however except a flow chart in the main text, see below, they are deeply buried in the paper’s supplement which can be accessed only online) without grading the presented evidence from randomized controlled and observational studies, it seems pertinent to judge, at least in part, whether respective suggestions have a sound scientific basis.
Claims and denials of clinically relevant effects of, in particular, non-surgical periodontal treatment on markers of diabetic control have not only led to a surge of new randomized clinical trials and systematic reviews thereof. If anybody had hope that the current frenzy has found a happy end with the updated and very comprehensive Cochrane review by Simpson et al. (2015) (s)he has been mistaken. In the June issue of the Australian Dental Journal, Botero et al. (2016) report on an umbrella review in which they systematically reviewed all systematic reviews on the subject, be it with or without meta-analysis, published between 1995 and 2015. The paper has been accepted for publication on January 20, 2016. It has to be emphasized that using the term “umbrella review” is somewhat misleading. In a strict sense, an umbrella review assembles together several systematic reviews on the same condition in the presence of many treatments or many important outcomes.