Improved clinical decision making using the evidence-based approach

Europe's contribution to the evaluation of the use of systemic antimicrobials in the treatment of periodontitis

This narrative review celebrates Europe's contribution to the current knowledge on systemically administered antimicrobials in periodontal treatment. Periodontitis is the most frequent chronic noncommunicable human disease. It is caused by dysbiotic bacterial biofilms and is commonly treated with subgingival instrumentation. However, some sites/patients do not respond adequately, and its limitations and shortcomings have been recognized. This has led to the development of alternative or adjunctive therapies. One is the use of antimicrobials to target bacteria in subgingival biofilms in the periodontal pocket, which can be targeted directly through the pocket entrance with a locally delivered antibiotic or systemically by oral, intravenous, or intramuscular methods. Since the early 20th century, several studies on systemic antibiotics have been undertaken and published, especially between 1990 and 2010. Europe's latest contribution to this topic is the first European Federation of Periodontology, S3-level Clinical Practice Guideline, which incorporates recommendations related to the use of adjuncts to treat stage I-III periodontitis. Understanding the etiopathogenesis of periodontal diseases, specifically periodontitis, has influenced the use of systemic periodontal antibiotic therapy. Randomized clinical trials and systematic reviews with meta-analyses have demonstrated the clinical advantages of adjunctive systemic antimicrobials. However, current recommendations are restrictive due to concerns about antibiotic misuse and the increase in microbial antibiotic resistance. European researchers have contributed to the use of systemic antimicrobials in the treatment of periodontitis through clinical trials and by providing rational guidelines. Nowadays, European researchers are exploring alternatives and directing clinical practice by providing evidence-based guidelines to limit the use of systemic antimicrobials.

Nonsurgical and surgical treatment of periodontitis: how many options for one disease?

Treatment of periodontitis aims at preventing further disease progression with the intentions to reduce the risk of tooth loss, minimize symptoms and perception of the disease, possibly restore lost periodontal tissue and provide information on maintaining a healthy periodontium. Therapeutic intervention includes introduction of techniques to change behavior, such as: individually tailored oral-hygiene instructions; a smoking-cessation program; dietary adjustment; subgingival instrumentation to remove plaque and calculus; local and systemic pharmacotherapy; and various types of surgery. No single treatment option has shown superiority, and virtually all types of mechanical periodontal treatment benefit from adjunctive antimicrobial chemotherapy. Periodontal treatment, because of the chronic nature of periodontitis, is a lifelong commitment to intricate oral-hygiene techniques, which, when properly implemented, will minimize the risk of disease initiation and progression.

Paying for treatments? Influences on negotiating clinical need and decision-making for dental implant treatment

Background

The aim of this study is to examine how clinicians and patients negotiate clinical need and treatment decisions within a context of finite resources. Dental implant treatment is an effective treatment for missing teeth, but is only available via the NHS in some specific clinical circumstances. The majority of people who receive this treatment therefore pay privately, often at substantial cost to themselves. People are used to paying towards dental treatment costs. However, dental implant treatment is much more expensive than existing treatments – such as removable dentures. We know very little about how dentists make decisions about whether to offer such treatments, or what patients consider when deciding whether or not to pay for them.

Methods/Design

Mixed methods will be employed to provide insight and understanding into how clinical need is determined, and what influences people's decision making processes when deciding whether or not to pursue a dental implant treatment. Phase 1 will use a structured scoping questionnaire with all the General dental practitioners (GDPs) in three Primary Care Trust areas (n = 300) to provide base-line data about existing practice in relation to dental implant treatment, and to provide data to develop a systematic sampling procedure for Phase 2. Phases 2 (GDPs) and 3 (patients) use qualitative focused one to one interviews with a sample of these practitioners (up to 30) and their patients (up to 60) to examine their views and experiences of decision making in relation to dental implant treatment. Purposive sampling for phases 2 and 3 will be carried out to ensure participants represent a range of socio-economic circumstances, and choices made.

Discussion

Most dental implant treatment is conducted in primary care. Very little information was available prior to this study about the quantity and type of treatment carried out privately. It became apparent during phase 2 that ISOD treatment was an unusual treatment in primary care. We thus extended our sample criteria for Phase 3 to include people who had had other implant supported restorations, although not single tooth replacements.

The challenges of transferring evidence-based dentistry into practice

The goal of evidence-based dentistry is to help practitioners provide their patients with optimal care. This is achieved by integrating sound research evidence with personal clinical expertise and patient values to determine the best course of treatment. Although clinicians embrace this concept, its implementation in clinical practice has been slow. In this article, barriers against the implementation of evidence-based care are examined and possible solutions are offered. The dental profession is committed to providing the best possible dental care for patients. This is proving to be more complex due to a virtual "information explosion" on new therapies, techniques, and materials; increased consumer understanding of treatment possibilities and therapeutic outcomes; and changing sociodemographic patterns. Although the profession advocates the importance of evidence-based dental disease prevention and treatment, practitioners have been slow to implement this concept. In 2003, the California Dental Association (CDA) formulated an evidence-based dentistry (EBD) action plan that included the formation of a task force to monitor EBD efforts and implement programs to educate CDA members on this methodology. The challenges of transferring EBD into clinical practice were key issues addressed by the task force, and much of their deliberations and perspectives are reflected in this article. Possible solutions for eliminating barriers against evidence-based care will also be explored.

Periodontal treatment practices of Finnish dentists

OBJECTIVES

To evaluate the treatment practices of Finnish general practitioners (GPs) and dental teachers (DTs) regarding periodontal treatment modalities, and their knowledge of possible contraindications for periodontal surgery.

MATERIAL AND METHODS

A questionnaire on two periodontal cases was mailed to 400 GPs, selected by stratified randomization from the public and private sector, and to 47 DTs. The response rate was 77%. Respondents were asked to choose the optimal treatment for a patient with a bleeding, 8-mm-deep periodontal pocket and to consider the influence on their treatment decision of the six possible contraindications for periodontal surgery presented, two of which were absolute (inadequate oral hygiene and poorly controlled diabetes) and four of which were relative contraindications. The respondents' treatment decisions were compared with recommendations from textbooks and the Consensus Report from the 1996 World Workshop of Periodontology.

RESULTS

The majority of public (65%) and private (70%) dentists and almost all of the DTs chose treatment in agreement with recommendations. Correct answers from dentists were associated with a greater number of days in continuing education (OR = 1.5; p= 0.005). The two absolute contraindications were known by 38% of public and 31% of private sector dentists, and by 29% of DTs. The respective figures for relative contraindications were 40, 58 and 53%.

CONCLUSION

The majority of Finnish dentists followed the recommendations, but elaboration of international guidelines for good clinical practice is still needed to help clinicians to make optimal treatment decisions.

In search of truth: the role of systematic reviews and meta-analyses for assessing the effectiveness of rehabilitation with oral implants

BACKGROUND

It is difficult to determine the effectiveness or potential harm of dental therapies. Thus, any tools able to condense reliable scientific information would be of benefit.

PURPOSE

To discuss methods for the assessment of the scientific literature and, in particular, of systematic reviews for evaluating the effectiveness of oral implant rehabilitation procedures.

MATERIALS AND METHODS

Various study designs and methods to identify scientific evidence are described, discussed, and ranked. Issues on how to critically appraise randomized controlled clinical trials (RCTs) and systematic reviews are presented.

RESULTS

Properly conducted RCTs and structured critical systematic reviews are the gold standard of clinical research for assessing whether a therapeutic intervention is effective. In the field of oral implantology, there is an urgent need to implement more RCTs and to summarize their results in systematic reviews.

CONCLUSIONS

Searching of the truth requires training and critical skill. Dentists should be trained on how to integrate their clinical experience with evidence-based research and on how to discriminate between clinically useful scientific information and less useful research.

Education in periodontology. A need for a new teaching model

The objectives of the present work were to elucidate faculty perceptions and effects on traditional teaching and the supplement of a problem-based learning model in periodontal education. Students and faculty members at one university were asked to respond to a battery of relevant questions in periodontology that had been previously discussed at two European academic workshops. Differences in responses were noticed both between faculty, students, and their responses as compared to responses given by participants at the European workshops. On several topics, faculty within the selected university held significantly different opinions. Thus lecture content and concepts may vary dependent on who gives the lecture and may not be consistent with the common interpretation of the scientific evidence. Responses given by those participating in the workshops indicated consensus. The study results suggest that students were able to extract appropriate conclusions from the scientific literature in the they were able to concede with an expert panel on specific issues studied. Students were however unable to convince other students, who had not participated in the specific activity, that their conclusions were consistent with the scientific evidence and different than what had been taught in class. In many cases, these conclusions differed from their previous perceptions obtained during traditional lectures. In conclusion, the present study suggests that problem-based learning activities should be introduced early in the curriculum to avoid bias in understanding which may occur when students have been previously exposed to information presented in standard lectures. The use of interactive teaching via internet is discussed.

Periodontal therapeutics--a viable option?

Research in recent years in periodontology has seen a shift from surgery towards medicine. While surgery, particularly regenerative, and including implants, continues to form an important element of periodontal treatment, the volume of treatment required and the results of recent and ongoing non-surgical studies clearly show that most future periodontics will be based on a physician-type approach. Improved diagnostics based on more precise periodontal disease classification, simplification of mechanical oral hygiene equipment and procedures, and the development of conventional and non-conventional chemical and physical adjuncts may be expected to reduce the rate of common periodontal disease advance, resulting in less complex treatments, and more of the latter coming to lie within the competence of the generalist and the hygienist working together. The rationale for non-surgical adjunctive therapy is extensive, far beyond the usual antimicrobial logic. It will also be important to control the oral microflora for systemic reasons, since increasingly strong links are being established between focal infection of oral origin, much of it periodontal, and a range of systemic diseases, including coronary heart disease, stroke, gastrointestinal disorders, and low birth weight, apart from severe, overt systemic infections. All these developments derive from a greatly improved understanding of the fundamentally ecological nature of the natural microbial biofilm that is dental plaque, and of its interactions with its human host.

Evidence-based periodontal treatment. Highlights from the 1996 World Workshop in Periodontics

State-of-the-art periodontal therapy involves a wide range of diagnostic and treatment options. The 1996 World Workshop in Periodontics used an evidence-based approach to assess the efficacy of many of these options. This article describes the evidence-based approach and summarizes the findings of the workshop in the areas of diagnosis and nonsurgical and surgical periodontal therapy as well as dental implants.