Periodontal Therapy: Patient Outcomes-Based or Profit Center-Based?

Multiple recent articles have called for outcomes-based and patient-centered guidelines for periodontal therapy.1-6 Simply put, periodontal therapy must be in accord with evidence-based treatment and doing what is right for the patient at the clinical level. With this in mind, the present authors contend that many patients with periodontal disease are not receiving acceptable and timely treatment and disease management.

Calculus as a Risk Factor for Periodontal Disease: Narrative Review on Treatment Indications When the Response to Scaling and Root Planing Is Inadequate.

BACKGROUND: Based on the 2018 classification of periodontal disease, a series of articles have been published describing the decision points of periodontal therapy and how the findings collected at those decision points can be used as guidelines for periodontal therapy. The articles are reviewed with a focus on the finding of inadequate calculus removal at the decision points and how that finding impacts treatment outcomes. METHODS: A narrative review of the literature discussing the influence of calculus on inflammation was performed and the effects of inadequate removal of calculus during periodontal therapy were analyzed in light of the 2018 classification of periodontal disease, the decision points of periodontal therapy, and the guidelines of periodontal therapy. RESULTS: The published literature supports that calculus is a major risk factor for periodontal inflammation. Recent studies indicate that the pathologic risk of calculus goes beyond the retention of biofilm and may represent a different pathophysiologic pathway for periodontal disease separate from the direct action of biofilm. The inadequate removal of calculus is a factor in the failure of periodontal therapy. CONCLUSIONS: The inadequate removal of calculus plays an important role in the frequent failure of non-surgical periodontal therapy to eliminate inflammation.

Clinical Decisions Based on the 2018 Classification of Periodontal Diseases.

The absence of widely accepted treatment decision points for the management of periodontitis can be problematic for the dental profession and patients. After conducting a thorough review of published peer-reviewed studies, the authors developed basic therapeutic decision points for the management of periodontitis based on the 2018 classification of periodontal diseases. These decision points were utilized to outline appropriate treatments, which include: patient commitment to a thorough daily self-care regimen, the definitive elimination of etiological factors, professional treatment that includes the complete removal of residual bacterial biofilm (plaque), the definitive removal of both supragingival and subgingival calculus, and, in advanced disease, possible tissue augmentation and regenerative surgery. Advanced therapies to accomplish an acceptable therapeutic end point are indicated in stage III and stage IV periodontitis. The presented decision points for the treatment of periodontitis offer a basis for the ethical care and management of patients in all stages of periodontitis.

Preparing Dental Students and Residents to Overcome Internal and External Barriers to Evidence-Based Practice.

In recent years, evidence-based dentistry has become the ideal for research, academia, and clinical practice. However, barriers to implementation are many, including the complexity of interpreting conflicting evidence as well as difficulties in accessing it. Furthermore, many proponents of evidence-based care seem to assume that good evidence consistently exists and that clinicians can and will objectively evaluate data so as to apply the best evidence to individual patients' needs. The authors argue that these shortcomings may mislead many clinicians and that students should be adequately prepared to cope with some of the more complex issues surrounding evidence-based practice. Cognitive biases and heuristics shape every aspect of our lives, including our professional behavior. This article reviews literature from medicine, psychology, and behavioral economics to explore the barriers to implementing evidence-based dentistry. Internal factors include biases that affect clinical decision making: hindsight bias, optimism bias, survivor bias, and blind-spot bias. External factors include publication bias, corporate bias, and lack of transparency that may skew the available evidence in the peer-reviewed literature. Raising awareness of how these biases exert subtle influence on decision making and patient care can lead to a more nuanced discussion of addressing and overcoming barriers to evidence-based practice.

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures.

The Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures evidence-based clinical practice guideline was codeveloped by the American Academy of Orthopaedic Surgeons (AAOS) and the American Dental Association. This guideline replaces the previous AAOS Information Statement, "Antibiotic Prophylaxis in Bacteremia in Patients With Joint Replacement," published in 2009. Based on the best current evidence and a systematic review of published studies, three recommendations have been created to guide clinical practice in the prevention of orthopaedic implant infections in patients undergoing dental procedures. The first recommendation is graded as Limited; this recommendation proposes that the practitioner consider changing the long-standing practice of routinely prescribing prophylactic antibiotic for patients with orthopaedic implants who undergo dental procedures. The second, graded as Inconclusive, addresses the use of oral topical antimicrobials in the prevention of periprosthetic joint infections. The third recommendation, a Consensus statement, addresses the maintenance of good oral hygiene.

State of the science: chronic periodontitis and systemic health.

CONTEXT: Inflammatory periodontal diseases exhibit an association with multiple systemic conditions. Currently, there is a lack of consensus among experts on the nature of these associations and confusion among health care providers and the public on how to interpret this rapidly growing body of science. This article overviews the current evidence linking periodontal diseases to diabetes, cardiovascular disease, osteoporosis, preterm low birth weight babies, respiratory diseases, and rheumatoid arthritis. EVIDENCE ACQUISITION: Evidence was taken from systematic reviews, clinical trials, and mechanistic studies retrieved in searches of the PubMed electronic database. The available data provide the basis for applied practical clinical recommendations. EVIDENCE SYNTHESIS: Evidence is summarized and critically reviewed from systematic reviews, primary clinical trials, and mechanistic studies CONCLUSIONS: Surrogate markers for chronic periodontitis, such as tooth loss, show relatively consistent but weak associations with multiple systemic conditions. Despite biological plausibility, shorter-term interventional trials have generally not supported unambiguous cause-and-effect relationships. Nevertheless, the effective treatment of periodontal infections is important to achieve oral health goals, as well as to reduce the systemic risks of chronic local inflammation and bacteremias. Inflammatory periodontal diseases exhibit an association with multiple systemic conditions. With pregnancy as a possible exception, the local and systemic effects of periodontal infections and inflammation are usually exerted for many years, typically among those who are middle-aged or older. It follows that numerous epidemiological associations linking chronic periodontitis to age-associated and biologically complex conditions such as diabetes, cardiovascular disease, osteoporosis, respiratory diseases, rheumatoid arthritis, certain cancers, erectile dysfunction, kidney disease and dementia, have been reported. In the coming years, it seems likely that additional associations will be reported, despite adjustments for known genetic, behavioral and environmental confounders. Determining cause-and-effect mechanisms is more complicated, especially in circumstances where systemic effects may be subtle. Currently, however, there is a lack of consensus among experts on the nature of these associations and confusion among health care providers and the public on how to interpret this rapidly growing body of science. This article overviews the current evidence linking periodontal diseases to diabetes, cardiovascular disease, osteoporosis, preterm/low birth weight babies, respiratory diseases, and rheumatoid arthritis.

Evidence-based clinical recommendations regarding screening for oral squamous cell carcinomas.

BACKGROUND: This article presents evidence-based clinical recommendations developed by a panel convened by the American Dental Association Council on Scientific Affairs. This report addresses the potential benefits and potential risks of screening for oral squamous cell carcinomas and the use of adjunctive screening aids to visualize and detect potentially malignant and malignant oral lesions. TYPES OF STUDIES REVIEWED: The panel members conducted a systematic search of MEDLINE, identifying 332 systematic reviews and 1,499 recent clinical studies. They selected 5 systematic reviews and 4 clinical studies to use as a basis for developing recommendations. RESULTS: The panel concluded that screening by means of visual and tactile examination to detect potentially malignant and malignant lesions may result in detection of oral cancers at early stages of development, but that there is insufficient evidence to determine if screening alters disease-specific mortality in asymptomatic people seeking dental care. CLINICAL IMPLICATIONS: The panel suggested that clinicians remain alert for signs of potentially malignant lesions or early-stage cancers while performing routine visual and tactile examinations in all patients, but particularly in those who use tobacco or who consume alcohol heavily. Additional research regarding oral cancer screening and the use of adjuncts is needed.

Nonfluoride caries-preventive agents: executive summary of evidence-based clinical recommendations.

BACKGROUND: In this article, the authors present evidence-based clinical recommendations regarding the use of nonfluoride caries preventive agents. The recommendations were developed by an expert panel convened by the American Dental Association (ADA)Council on Scientific Affairs. The panel addressed several questions regarding the efficacy of nonfluoride agents in reducing the incidence of caries and arresting or reversing the progression of caries. TYPES OF STUDIES REVIEWED: A panel of experts convened by the ADA Council on Scientific Affairs, in collaboration with ADA Division of Science staff, conducted a MEDLINE search to identify all randomized and nonrandomized clinical studies regarding the use of non fluoride caries-preventive agents. RESULTS: The panel reviewed evidence from 50 randomized controlled trials and 15 nonrandomized studies to assess the efficacy of various nonfluoride caries-preventive agents. CLINICAL IMPLICATIONS: The panel concluded that certain nonfluoride agents may provide some benefit as adjunctive therapies in children and adults at higher risk of developing caries. These recommendations are presented as a resource for dentists to consider in the clinical decision-making process. As part of the evidence based approach to care, these clinical recommendations should be integrated with the practitioner's professional judgment and the patient's needs and preferences.