Last weekend, EFP and International Diabetes Federation (IDF) delegates, in partnership with Sunstar, had met in Madrid and had worked on guidelines for dentists, medical doctors and patients with periodontitis and/or diabetes. The EFP website features some key findings when reviewing the literature. In particular, it is claimed that,
evidence suggests that periodontitis patients have a higher chance of developing pre-diabetes and type-2 diabetes and that people with periodontitis and diabetes have more difficulty in keeping their blood-sugar levels under control. Furthermore, patients with both diseases are more likely to develop diabetic complications than people with diabetes without periodontitis.
Current evidence indicates that in people with diabetes, periodontal therapy accompanied by effective self-performed oral hygiene at home is both safe and effective – even in people with poorly controlled diabetes. Similarly, there is consistent evidence that periodontal therapy reduces blood-sugar levels in people with diabetes and periodontitis. (Emphasis added.)
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.
In a previous post, I have expressed considerable concern about an assumed advertorial in our leading periodontal journal, JCP. Quintessence Publishing was about to launch their fourth installment of “3D” animated, short (each 15-17 min) movies all called Cell-to-Cell Communication, “Oral Health and General Health – The Links between Periodontitis, Atherosclerosis, and Diabetes.” Previous movies have been offered for purchase by QuintPub for a remarkable amount of around $100. Luckily, the new one can now be found on the EFP homepage and accessed by members and non-members for free.
The recent largely expanded Cochrane Systematic Review on periodontal treatment for glycemic control in diabetics by Simpson et al. 2015 calculates, in one of numerous meta-analyses, a weighted mean 0.29% reduction (95% confidence interval 0.10% lower to 0.48% lower) of HbA1c 3-4 months after nonsurgical periodontal therapy. Fourteen clinical trials were considered comprising about 1499 patients with both diabetes and periodontitis. The quality of evidence was considered low. Quality was downgraded twice, first for risk of bias, mainly due to lack of blinding; and then due to moderate heterogeneity (I2 = 0.53%). The observed small reduction of 0.29% was not sustained afterwards . At 6-month follow-up (the meta-analysis considered 5 studies with 826 patients), the weighted mean reduction was 0.02% (95% CI 0.20% lower to 0.16% higher).
Any dental student in Germany would certainly fail his/her final exam if carelessly talking about the role of “fluor” in preventive dentistry. An assumed power of environmentalist pressure groups is very much feared among cariologists who want to make sure that it is fluoride, not fluorine, which has its most important part in the prevention and early treatment of dental caries. One possible accident of a child ingesting several fluoride tablets would suffice to provide environmentalists with further arguments. Elemental fluorine is highly toxic, in contrast to fluoride which is not so toxic, and environmentalist propagandists have used the public’s lack of knowledge to differentiate for manipulating public opinion against water fluoridation and further application and wide distribution of fluorides which have certaily resulted in most of the observed post WWII caries decline in all industrialized countries. So, dental students are advised to be precise. Fluorides are used in preventive dentistry, not highly toxic fluorine (“fluor”). As table salt is not chlorine!
The frenzy about fluorides in cariology appears to be based on the concept that dental caries is a result of fluoride deficiency. While it is undisputed that modern oral hygiene includes daily toothbrushing with fluoridated toothpaste (1450 ppm), additional application of, for instance, fluoride mouthwash may be restricted, based on current evidence, to caries-active individuals, in particular between 6 and 18 years. Most recently, 0.5% to 1% chlorhexidine gel alone or in combination with fluoride or 0.12% chlorhexidine mouthwash alone or with fluoride for prevention of coronal caries was not recommended, based on expert opinion in the former and strong experimental evidence in the latter case. Continue reading