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.
Concerns about increasing antibiotic resistance (e.g., methicillin-resistant Staphylococcus aureus, multidrug-resistant tuberculosis, antibiotic resistance of bacteria causing common infections of the urinary tract, pneumonia, or bloodstream infections), which jeopardizes effective prevention and treatment of life-threatening infections should be taken seriously when considering adjunct antibiotic therapy of periodontal diseases. After all, periodontal infections are not life-threatening diseases and can usually be controlled without adjunctive antibiotics. Apart from generalized severe cases, chronic periodontitis should not be treated in the first place with adjunct systemic antibiotics. In cases of aggressive or refractory periodontitis, microbiological diagnosis may allow targeting specific pathogens such as Aggregatibacter actinomycetemcomitans or Porphyromonas gingivalis. Responsible use of antibiotics takes into account the possible development of bacterial resistance, antibiotic toxicity and the risk of sensitizing.
Moreover, reducing the need for periodontal surgery by adjunct antibiotics may be short-sighted (note that I had written about this on several occasions here on this blog). Anatomical defects such as furcation involvement and infrabony lesions, which are the main indications for periodontal surgery, won’t resolve after subgingival scaling and adjunct antibiotic treatment. In light of the global problem of antibiotic resistance, any recommendation for repeat courses of antibiotic therapy to reduce the need for minor surgical intervention in a not life-threatening disease should be considered inappropriate.
It was tempting to write another post in the Periodontal Myths and Mystery Series – Clinical Measurements in Periodontal Disease. Guesswork whenever it comes to submarginal landmarks such as the cemento-enamel junction and bottom of the pocket; or, even worse, an assumed “tangent to the prominences of two roots” to “measure” furcation involvement. After having introduced and refined case definitions of mild, moderate and severe periodontitis for epidemiological surveys in the past decade, the same authors representing the American Academy of Periodontology and the U.S. Centers for Disease Control and Prevention had to concede, in a recent article in the Journal of Periodontology, that,
[t]hese subgroups [mild and moderate periodontitis] are not truly ordinal [sic] as the label suggests because many ‘moderate’ cases had insufficient pocket depth to qualify as ‘mild’ and we have therefore combined them and used the label ‘other‘ periodontitis,
adding even more confusion . When the paper went online earlier this year, I had contacted one of the authors, Dr. Wenche Borgnakke, to explain that sentence. I had even suggested,
So, in some cases there was >= 4mm CAL but no deep pockets of >=5mm, only 4mm. So, if CAL would have been 3mm, one would have assigned it to ‘mild’, but since it was 4+mm, it had been ‘moderate,’
asking her whether I was possibly right. Unfortunately, she did not respond.
Students and colleagues will certainly remember my harsh criticism of a not-anymore-so-novel ultrasonic scaler, PerioScan, of which its manufacturer claims that it might be able to detect remaining subgingival calculus. According to the manufacturer Sirona,
“PerioScan is an ultrasonic unit with treatment and diagnosis all-in-one, thereby offering new dimensions [sic] to periodontology. The unit detects and removes calculus by using a gentle method of treatment preventing the accumulation which causes periodontitis.
The tooth surfaces are being analysed by the touch of the ultrasonic tip (scaler) on the basis of the physical oscillation pattern. Indicator for the presence of calculus on the root surface is the blue LED lighting integrated into the tip of the handpiece. The LED colour changes to green when it contacts healthy surface. Two containers allow the use of different irrigating liquids during treatment.
The user interface is large and clear so that the user can have a glance at the data and the settings during the treatment at all times. The design impression and the colour concept of the interface are a reference for present and future projects of the entire product range of Sirona.”
The rationale for the devolpment of a smart device for both detecting (based on “fuzzy-pattern recognition”) and removing calculus (by conventional ultrasound) has certainly been recognition of a common disadvantage of any ultrasonic scaling device: its lack of tactile control of whether the entire subgingival root surface has actually been machined. I had used this device for years as a striking example for lack of clinical evidence after 20 years of development, apart from a 2008 pilot study (which actually tested validity of calculus assessment after extraction of the teeth), that it may actually lead to better results as regards the clinical response to subgingival scaling which might justify rather high acquisition costs. But there is more which should be used for teaching undergraduates.
Members of the American Academy of Periodontology have been alerted yesterday evening by the publication of a large (more than 500 patients were enrolled) phase 3, single-masked, multicenter, randomized, 6-month intervention study on moderate to severe chronic periodontitis patients with diabetes type 2 taking stable doses of anti-diabetic medication. Engebretson et al. 2013 report in JAMA that basic periodontal treatment, i.e., scaling and root planing, did not lead to a reduction of HbA1c levels. Instead, HbA1c levels had slightly increased after 6 months, in test subjects receiving basic periodontal treatment even slightly more (normalized mean 0.17%) than in the control group (normalized mean 0.11%) where basic treatment was postponed. The difference was not significant.
Results Enrollment was stopped early because of futility. At 6 months, mean HbA1c levels in the periodontal therapy group increased 0.17% (SD, 1.0), compared with 0.11% (SD, 1.0) in the control group, with no significant difference between groups based on a linear regression model adjusting for clinical site (mean difference, −0.05% [95% CI, −0.23% to 0.12%]; P = .55). Periodontal measures improved in the treatment group compared with the control group at 6 months, with adjusted between-group differences of 0.28 mm (95% CI, 0.18 to 0.37) for probing depth, 0.25 mm (95% CI, 0.14 to 0.36) for clinical attachment loss, 13.1% (95% CI, 8.1% to 18.1%) for bleeding on probing, and 0.27 (95% CI, 0.17 to 0.37) for gingival index (P < .001 for all).
Conclusions and Relevance Nonsurgical periodontal therapy did not improve glycemic control in patients with type 2 diabetes and moderate to advanced chronic periodontitis. These findings do not support the use of nonsurgical periodontal treatment in patients with diabetes for the purpose of lowering levels of HbA1c.