Tagged: periodontal treatment
My Periodontal Medicine Evening Seminar in Berlin
Early in 2016, I had been invited by the Berlin Society of Periodontology for giving an evening seminar at the University Dental School of Charité. As I had dedicated considerable time and effort for unveiling details and peculiarities of the so-called Engebretson scandal which had concomitantly been published on this blog, I found the invitation an excellent opportunity to share my views on the scandal with a distinguished auditorium of Berlin periodontists who, after all, had been trained and educated by late Professor Jean-Pierre Bernimoulin. Bernimoulin had passed in September 2015 and I confirmed in the introduction of my seminar that he had actually been the only periodontist in Germany (he was originally from Belgium) of international stature in his time.
Continue readingSome Remarks on “100 Years of Progress in Periodontal Medicine” (II) – Diabetes Mellitus
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That periodontitis and diabetes mellitus are related is known for more than 100 years. While Beck et al. (2019), in their contribution to the JDR Centennial Series on 100 Years of Progress in Periodontal Medicine, start out with a paper by Williams and Mahan (1960), which is mentioned as the first landmark paper (allegedly the first study showing that periodontal therapy reduces insulin requirement; but this study had only shown that removing all teeth with advanced decay improved glycemic control), the latter authors quote a booklet by Otto Georg Grunert of 1899 a patient guidebook for diabetics: Ueber Krankheitserscheinungen in der Mundhöhle beim Diabetes: Therapeutische Winke für Diabetiker. In particular the medical profession had known about the link of diabetes mellitus and oral disease for long.
Further landmark, or “milestone”, papers in Beck et al.’s list on the diabetes-periodontitis relationship appeared around 1996, when late Professor Robert J. Genco, for the first time, had used a slide with the message, Floss or Die! on the occasion of the annual meeting of the American Academy of Periodontology in New Orleans. Some of these studies indeed sparked the idea that it would be possible to reduce HbA1c, the marker of diabetic control, by proper periodontal treatment of diabetic patients.
Periodontal Therapy For the Management of Cardiovascular Disease in Patients With Chronic Periodontitis
The issue mentioned in the title was dealt with in a systematic review of the Cochrane Collaboration which was published 3 1/2 years ago. It confirmed that, since the publication of the PAVE pilot study in 2009, no further evidence had emerged. The authors of the Cochrane review concluded,
We found very low quality evidence that was insufficient to support or refute whether periodontal therapy can prevent the recurrence of CVD in the long term in patients with chronic periodontitis. No evidence on primary prevention was found.
Possible systemic effects of periodontal treatment had been claimed for a very long time, and lack of evidence, or evidence for their clinical irrelevance, had never been accepted by many colleagues, indeed.
The most recent attempt of reviving the largely lapsed interest by most of our medical colleagues in the Perio-Systemic link, in particular its cardiovascular branch, was launched earlier this week when a delegation of the European Federation of Periodontology (EFP) met colleagues of the World Heart Federation (WHF) in Madrid. The aim of the workshop was to “explore the links between periodontal disease and cardiovascular disease and draw up a series of recommendations.”
Prediabetics, Subgingival Scaling and the Regression Towards the Mean
There is still controversy about the meaningfulness of HbA1c reduction in diabetics upon non-surgical periodontal therapy. One may get the impression that the number of systematic reviews (SR) on the issue surpasses the number of quality randomized clinical trials (RCT). The most current update by the Cochrane Collaboration (Simpson et al. 2015) had concluded that,
There is low quality evidence that the treatment of periodontal disease by SRP [scaling and root planing] does improve glycaemic control in people with diabetes, with a me an percentage reduction in HbA1c of 0.29% at 3-4 months; however, there is insufficient evidence to demonstrate that this is maintained after 4 months.
I will stick to that statement although I am fully aware that attempts are being made by representatives of our profession of considering rather systematic reviews of SRs as if that would lead to other research outcomes. For still interested readers, I have reported and discussed the issue in numerous blog posts, see e.g. here, here and here.
Treating all kinds of systemic ailments by proper scaling and root planing has been an illusion of certain periodontists for some time. As a healthy antidot, one should carefully read an interview with Jan Lindhe, published some time ago, where he warned us:
I think that the dentist’s area is pretty well described – it’s intraoral and also maxillofacial in a sense but the dentist shouldn’t be a pseudo-doctor for all types of disorders. (Emphasis added.)
New Updates On the Perio-Diabetes Link
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.
Periodontology 