The EFP website has posted the other day a debate between Professors Lior Shapira of the Jerusalem Hebrew University and Andrea Mombelli, Geneva. Is it time to rethink on the use of antibiotics in the treatment of periodontitis? Well, it actually is. One cannot continue just emphasizing the undeniable (if short-term) effect of antibiotics reducing the need and extent of periodontal surgery when administered as an adjunct to non-surgical treatment (Mombelli) without having the much bigger picture (real global threats of antibiotic resistance development) in mind (Shapiro). I have written about recent respective clinical reports on (transient) effects of adjunct antibiotics numerous times on this blog, see, for example here, here and here. I never concealed my opinion. Biofilm infections are indeed different.
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.
In an announcement for his talk about periodontal treatment effects on type 2 diabetes at Europerio 8 in London later this year, exasperated Professor Thomas Kocher of Greifswald University in Germany promises to “dissect” the large multicenter trial by Engebretson et al. (2013) who could not find an effect on glycated hemoglobin in type 2 diabtes mellitus. The study had been published in late 2013 in JAMA, not in New England (Journal of Medicine). The large multicenter trial had long been attacked for not yielding the desired results (“a publication which we were really waiting for”).
Kocher was asked to talk in London about “why all the other small studies showed an effect” and he wants to find out “the issues why we [?] couldn’t see anything in the Engebretson study”. Well, it was actually Wenche Borgnakke who had got 20 other “reviewers” aboard who had already dissected the study by Engebretson et al. and has called for censorship.
As noted by Engebretson and Kocher 2013 in one of the numerous previous systematic reviews of RCTs on the effect of nonsurgical periodontal therapy and reported in Table 1 of their article, problems with the design of these small-scale, mainly single-center studies, which included some trials with adjunctive antibiotics, were plentiful. Problems with low and high baseline HbA1c levels and with questionable periodontal outcomes had been reported as well. Engebretson and Kocher (2013) report possible publication bias which means nothing else that studies without an effect on HbA1c might have gone unpublished. Based on this particular and numerous other systematic reviews, the evidence that nonsurgical periodontal therapy in fact has a relevant beneficial effect on HbA1c levels in type 2 diabetics may actually be regarded moderate. The study by Engebretson et al. adds heterogeneity to any meta-analysis which may downgrade this evidence to low. That is what our thought leaders alerts. That’s why censorship.
The first withdrawn manuscript by Drs. Wenche Borgnakke and Iain Chapple and each and every editor of our hardcore periodontal journals as well as otherwise eminent individual in Periodontology, which had proclaimed that “[t]he randomized controlled trial (RCT) published by the Journal of the American Medical Association (JAMA) on the impact of periodontal therapy on glycated hemoglobin (HbA1c) has fundamental flaws” about the paper by Engebretson et al. (2013), see [pdf], went online today in the Journal of Evidence-Based Dental Practice.
I had wondered before why it had been withdrawn but couldn’t figure that out. Interesting may be that the withdrawn paper had listed all 19 authors, while the current version does not. Maybe that Borgnakke and Chapple are only pawns in a worldwide political enterprise launched by our “thought leaders”. It may also be that more “evidence” (see below), possibly (but rather not) suitable for putting findings by Engebretson et al. (2013) into perspectve, needed to be included in what is almost a revile.