- Email: [email protected]
More about scaling and root planing
COMMENTARIES
LETTERS
J
ADA welcomes letters from readers on articles that have appeared in The Journal. The Journal reserves the right to edit all communications and requires that all letters be signed. Letters must be no more than 550 words and must cite no more than five references. No illustrations will be accepted. A letter concerning a recent JADA article will have the best chance of acceptance if it is received within two months of the article’s publication. For instance, a letter about an article that appeared in April JADA usually will be considered for acceptance only until the end of June. You may submit your letter via e-mail to [email protected]; by fax to 1-312-440-3538; or by mail to 211 E. Chicago Ave., Chicago, IL 60611-2678. By sending a letter to the editor, the author acknowledges and agrees that the letter and all rights of the author in the letter sent become the property of The Journal. Letter writers are asked to disclose any personal or professional affiliations or conflicts of interest that readers may wish to take into consideration in assessing their stated opinions. The views expressed are those of the letter writer and do not necessarily reflect the opinion or official policy of the Association. Brevity is appreciated.
SCALING AND ROOT PLANING
This is a response to the article, “Systematic Review and Metaanalysis on the Nonsurgical Treatment of Chronic Periodontitis by Means of Scaling and Root Planing With or Without Adjuncts” (Smiley CJ, Tracy SL, Abt E, et al. JADA. 2015;146[7]:508-524.e5). As an active life member of the American Dental Association, I am perplexed at the conclusions of this article with regard to the adjunctive use of lasers for the purpose of pocket decontamination. After more than 25 years of active full-time practice with various wavelengths of lasers, my observations and measurements of healthy outcomes are the opposite of the conclusions of this meta-analysis. The scaling and root planing technique itself has no accepted protocols. Where is it stated that we clinicians should use ultrasonic, piezo, or hand instrumentation to achieve an anatomic result that is impossible to quantify at the chair except by tissue response? The measurement of health involves a lot more than “clinical attachment levels.” Realistically, we clinicians measure tissue color, texture, pocket depths, mobility, and bleeding indexes as true clinical indicators of tissue health.
It is disappointing to me that so few articles favorable to the use of lasers were cited in the study compared with the abundance of adjunctive pharmaceutical studies cited. As a certified dental laser educator, and having trained thousands of dentists and dental hygienists over the past 20 years, I have only received positive feedback as to the efficacy of laser adjunctive treatment. More than 30,000 offices in North America use lasers in everyday practice (Densen Cao, PhD, October 10, 2015, e-mail communication). Pocket decontamination with various wavelengths is the second most common procedure in general practice. Every laser manufacturer has had to show clinical efficacy and safety with specific power and pulse recommendations to the US Food and Drug Administration for marketing approval. The Academy of Laser Dentistry, founded in 1993, is the only dental organization in North America dedicated to noncommercial laser education. It is unfortunate that the American Dental Association Council on Scientific Affairs chose not to include any of its members on the panel of reviewers. Nonetheless, we would be pleased to serve and invite any of the members of the Council or the reviewing group to
our annual meeting in April 2016. Lasers in periodontics is a chief element of the meeting. The Academy is currently in the process of assisting the National Dental Practice-based Research Network organization in study design on this topic. Science can only be advanced when a profession is open-minded to new treatment modalities. John J. Graeber, DMD, MAGD, MALD, FICD President Academy of Laser Dentistry East Hanover, NJ
http://dx.doi.org/10.1016/j.adaj.2015.10.007 Copyright ª 2015 American Dental Association. All rights reserved.
MORE ABOUT SCALING AND ROOT PLANING
On behalf of the over 8,000 members of the American Academy of Periodontology (AAP), I would like to convey our appreciation to JADA for publishing, “Evidence-Based Clinical Practice Guideline on the Nonsurgical Treatment of Chronic Periodontitis by Means of Scaling and Root Planing With or Without Adjuncts” (Smiley CJ, Tracy SL, Abt E, et al. JADA. 2015;146[7]: 525-535). For many patients, nonsurgical periodontal therapy is often the first line of defense against further disease progression. The guideline may be helpful in determining which nonsurgical approach may yield the most predictable outcomes. The AAP concurs with the authors, 7 of whom were periodontists, that scaling and root planing (SRP) should be used as the initial nonsurgical treatment option for chronic periodontitis. The AAP also agrees with the authors’ findings with respect to adjunctive therapies. As described in the guideline, none of the adjunctive therapies, including systemic antimicrobials, systemic host modulators, locally delivered antimicrobials, and lasers (when used nonsurgically), result in a greater gain in clinical attachment
JADA 146(12) http://jada.ada.org
December 2015 865
COMMENTARIES
loss over SRP alone. In addition, some adjunctive therapies, such as the diode, neodymium-doped yttrium aluminum garnet and erbium-doped yttrium aluminum garnet lasers, yield no additional benefit over SRP alone. The guideline supports that clinicians must look to the evidence and let research guide our treatment decisions. Although SRP remains the cornerstone of nonsurgical treatment, it is important to note that the comprehensive management of chronic periodontitis often requires more advanced therapy. Depending on the case, your treatment plan may also include individualized oral hygiene education; in-depth medical, social, and psychiatric assessment; occlusal evaluation; post-SRP re-evaluation; potential surgical therapy; and ongoing maintenance. Every patient is unique, and practitioners must base all periodontal treatment decisions—both nonsurgical and surgical—on an individual basis. The patient’s risk for developing future or advanced disease should be carefully considered, expected outcomes and consequences of nontreatment clearly communicated, and clinical end points established and cautiously measured. For general dentists, a consultation with a periodontist may be warranted, especially when dealing with a complex case or a medically compromised patient. Working together, we can establish a course of action that will result in the best possible care. Joan Otomo-Corgel, DDS, MPH President American Academy of Periodontology Manhattan Beach, CA
http://dx.doi.org/10.1016/j.adaj.2015.10.008 Copyright ª 2015 American Dental Association. All rights reserved.
LASER USE IN SCALING AND ROOT PLANING
The “sound scientific basis and proven efficacy in order to ensure public safety” is one of the main
866 JADA 146(12) http://jada.ada.org
eligibility requirements of the American Dental Association Continuing Education Recognition Program (CERP) Recognition Standards and Procedures.1 Until such sound scientific foundation for nonsurgical, nonphotodynamic therapy, laser-assisted treatment of chronic periodontitis can be established, including science-based protocols with predictable and reproducible results, one would hope that responsible CERPcertified continuing dental education providers will not promote the laser use that is advised against in the 2 July JADA articles, “Systematic Review and Meta-analysis on the Nonsurgical Treatment of Chronic Periodontitis by Means of Scaling and Root Planing With or Without Adjuncts” (Smiley CJ, Tracy SL, Abt E, et al. JADA. 2015;146[7]: 508-524.e5) and “Evidence-Based Clinical Practice Guideline on the Nonsurgical Treatment of Chronic Periodontitis by Means of Scaling and Root Planing With or Without Adjuncts” (Smiley CJ, Tracy SL, Abt E, et al. JADA. 2015;146[7]: 525-535). Peter Vitruk, PhD, MInstP, CPhys Founder, LightScalpel–Aesculight– Luxarcare Woodinville, WA and Member, The Institute of Physics London, United Kingdom and Member, Science and Research Committee, Academy of Laser Dentistry Coral Springs, FL and Faculty, Global Laser Oral Health Scottsdale, AZ and Faculty, California Implant Institute San Diego, CA
http://dx.doi.org/10.1016/j.adaj.2015.10.009 Copyright ª 2015 American Dental Association. All rights reserved.
1. American Dental Association Commission for Continuing Education Provider Recognition. ADA CERP Eligibility Criteria. Available at: www.ada.org/en/ccepr/for-ce-providers/ application-process/eligibility-criteria. Accessed October 15, 2015.
December 2015
Authors’ response: The authors thank Dr. Graeber for his comments and suggestions. The authors agree with the statement: “science can only be advanced when a profession is open-minded to new treatment modalities”; however, in developing clinical guidelines, it is equally important that such treatments be evaluated with the same scientific rigor used to evaluate conventional or established treatments. Dr. Graeber lamented that “so few articles favorable to the use of lasers were cited [in the systematic review].” In conducting a systematic review, it is important that studies be selected and critiqued using prespecified, detailed, and established rules of evidence-based medicine and dentistry. The systematic review and guidelines considered only randomized controlled trials that were at least 6 months in duration. The panel noted that this 6-month criterion is used for the US Food and Drug Administration’s approval of drugs for the treatment or prevention of gingivitis.1 In addition, the panel was concerned that studies of 3 months’ duration may show a benefit that may not be sustainable over a 6- to 12-month period. Dr. Graeber also challenged the selection of clinical attachment loss as the sole measure to assess treatment effectiveness. We agree that clinicians can use a variety of clinical, radiographic, and even microbiological outcomes to evaluate a patient’s response to therapy, and the expert panel considered a broad range of outcomes before selecting clinical attachment level (CAL) for its literature search. As discussed in our review, although probing depth is the primary diagnostic tool used in clinical practice, CAL is commonly reported in the scientific literature as a valid measurement of disease progression and has long been viewed as a primary therapeutic outcome by advisory groups and regulatory agencies, including the US Food and Drug Administration. Use of probing depth as the primary
LETTERS
J
ADA welcomes letters from readers on articles that have appeared in The Journal. The Journal reserves the right to edit all communications and requires that all letters be signed. Letters must be no more than 550 words and must cite no more than five references. No illustrations will be accepted. A letter concerning a recent JADA article will have the best chance of acceptance if it is received within two months of the article’s publication. For instance, a letter about an article that appeared in April JADA usually will be considered for acceptance only until the end of June. You may submit your letter via e-mail to [email protected]; by fax to 1-312-440-3538; or by mail to 211 E. Chicago Ave., Chicago, IL 60611-2678. By sending a letter to the editor, the author acknowledges and agrees that the letter and all rights of the author in the letter sent become the property of The Journal. Letter writers are asked to disclose any personal or professional affiliations or conflicts of interest that readers may wish to take into consideration in assessing their stated opinions. The views expressed are those of the letter writer and do not necessarily reflect the opinion or official policy of the Association. Brevity is appreciated.
SCALING AND ROOT PLANING
This is a response to the article, “Systematic Review and Metaanalysis on the Nonsurgical Treatment of Chronic Periodontitis by Means of Scaling and Root Planing With or Without Adjuncts” (Smiley CJ, Tracy SL, Abt E, et al. JADA. 2015;146[7]:508-524.e5). As an active life member of the American Dental Association, I am perplexed at the conclusions of this article with regard to the adjunctive use of lasers for the purpose of pocket decontamination. After more than 25 years of active full-time practice with various wavelengths of lasers, my observations and measurements of healthy outcomes are the opposite of the conclusions of this meta-analysis. The scaling and root planing technique itself has no accepted protocols. Where is it stated that we clinicians should use ultrasonic, piezo, or hand instrumentation to achieve an anatomic result that is impossible to quantify at the chair except by tissue response? The measurement of health involves a lot more than “clinical attachment levels.” Realistically, we clinicians measure tissue color, texture, pocket depths, mobility, and bleeding indexes as true clinical indicators of tissue health.
It is disappointing to me that so few articles favorable to the use of lasers were cited in the study compared with the abundance of adjunctive pharmaceutical studies cited. As a certified dental laser educator, and having trained thousands of dentists and dental hygienists over the past 20 years, I have only received positive feedback as to the efficacy of laser adjunctive treatment. More than 30,000 offices in North America use lasers in everyday practice (Densen Cao, PhD, October 10, 2015, e-mail communication). Pocket decontamination with various wavelengths is the second most common procedure in general practice. Every laser manufacturer has had to show clinical efficacy and safety with specific power and pulse recommendations to the US Food and Drug Administration for marketing approval. The Academy of Laser Dentistry, founded in 1993, is the only dental organization in North America dedicated to noncommercial laser education. It is unfortunate that the American Dental Association Council on Scientific Affairs chose not to include any of its members on the panel of reviewers. Nonetheless, we would be pleased to serve and invite any of the members of the Council or the reviewing group to
our annual meeting in April 2016. Lasers in periodontics is a chief element of the meeting. The Academy is currently in the process of assisting the National Dental Practice-based Research Network organization in study design on this topic. Science can only be advanced when a profession is open-minded to new treatment modalities. John J. Graeber, DMD, MAGD, MALD, FICD President Academy of Laser Dentistry East Hanover, NJ
http://dx.doi.org/10.1016/j.adaj.2015.10.007 Copyright ª 2015 American Dental Association. All rights reserved.
MORE ABOUT SCALING AND ROOT PLANING
On behalf of the over 8,000 members of the American Academy of Periodontology (AAP), I would like to convey our appreciation to JADA for publishing, “Evidence-Based Clinical Practice Guideline on the Nonsurgical Treatment of Chronic Periodontitis by Means of Scaling and Root Planing With or Without Adjuncts” (Smiley CJ, Tracy SL, Abt E, et al. JADA. 2015;146[7]: 525-535). For many patients, nonsurgical periodontal therapy is often the first line of defense against further disease progression. The guideline may be helpful in determining which nonsurgical approach may yield the most predictable outcomes. The AAP concurs with the authors, 7 of whom were periodontists, that scaling and root planing (SRP) should be used as the initial nonsurgical treatment option for chronic periodontitis. The AAP also agrees with the authors’ findings with respect to adjunctive therapies. As described in the guideline, none of the adjunctive therapies, including systemic antimicrobials, systemic host modulators, locally delivered antimicrobials, and lasers (when used nonsurgically), result in a greater gain in clinical attachment
JADA 146(12) http://jada.ada.org
December 2015 865
COMMENTARIES
loss over SRP alone. In addition, some adjunctive therapies, such as the diode, neodymium-doped yttrium aluminum garnet and erbium-doped yttrium aluminum garnet lasers, yield no additional benefit over SRP alone. The guideline supports that clinicians must look to the evidence and let research guide our treatment decisions. Although SRP remains the cornerstone of nonsurgical treatment, it is important to note that the comprehensive management of chronic periodontitis often requires more advanced therapy. Depending on the case, your treatment plan may also include individualized oral hygiene education; in-depth medical, social, and psychiatric assessment; occlusal evaluation; post-SRP re-evaluation; potential surgical therapy; and ongoing maintenance. Every patient is unique, and practitioners must base all periodontal treatment decisions—both nonsurgical and surgical—on an individual basis. The patient’s risk for developing future or advanced disease should be carefully considered, expected outcomes and consequences of nontreatment clearly communicated, and clinical end points established and cautiously measured. For general dentists, a consultation with a periodontist may be warranted, especially when dealing with a complex case or a medically compromised patient. Working together, we can establish a course of action that will result in the best possible care. Joan Otomo-Corgel, DDS, MPH President American Academy of Periodontology Manhattan Beach, CA
http://dx.doi.org/10.1016/j.adaj.2015.10.008 Copyright ª 2015 American Dental Association. All rights reserved.
LASER USE IN SCALING AND ROOT PLANING
The “sound scientific basis and proven efficacy in order to ensure public safety” is one of the main
866 JADA 146(12) http://jada.ada.org
eligibility requirements of the American Dental Association Continuing Education Recognition Program (CERP) Recognition Standards and Procedures.1 Until such sound scientific foundation for nonsurgical, nonphotodynamic therapy, laser-assisted treatment of chronic periodontitis can be established, including science-based protocols with predictable and reproducible results, one would hope that responsible CERPcertified continuing dental education providers will not promote the laser use that is advised against in the 2 July JADA articles, “Systematic Review and Meta-analysis on the Nonsurgical Treatment of Chronic Periodontitis by Means of Scaling and Root Planing With or Without Adjuncts” (Smiley CJ, Tracy SL, Abt E, et al. JADA. 2015;146[7]: 508-524.e5) and “Evidence-Based Clinical Practice Guideline on the Nonsurgical Treatment of Chronic Periodontitis by Means of Scaling and Root Planing With or Without Adjuncts” (Smiley CJ, Tracy SL, Abt E, et al. JADA. 2015;146[7]: 525-535). Peter Vitruk, PhD, MInstP, CPhys Founder, LightScalpel–Aesculight– Luxarcare Woodinville, WA and Member, The Institute of Physics London, United Kingdom and Member, Science and Research Committee, Academy of Laser Dentistry Coral Springs, FL and Faculty, Global Laser Oral Health Scottsdale, AZ and Faculty, California Implant Institute San Diego, CA
http://dx.doi.org/10.1016/j.adaj.2015.10.009 Copyright ª 2015 American Dental Association. All rights reserved.
1. American Dental Association Commission for Continuing Education Provider Recognition. ADA CERP Eligibility Criteria. Available at: www.ada.org/en/ccepr/for-ce-providers/ application-process/eligibility-criteria. Accessed October 15, 2015.
December 2015
Authors’ response: The authors thank Dr. Graeber for his comments and suggestions. The authors agree with the statement: “science can only be advanced when a profession is open-minded to new treatment modalities”; however, in developing clinical guidelines, it is equally important that such treatments be evaluated with the same scientific rigor used to evaluate conventional or established treatments. Dr. Graeber lamented that “so few articles favorable to the use of lasers were cited [in the systematic review].” In conducting a systematic review, it is important that studies be selected and critiqued using prespecified, detailed, and established rules of evidence-based medicine and dentistry. The systematic review and guidelines considered only randomized controlled trials that were at least 6 months in duration. The panel noted that this 6-month criterion is used for the US Food and Drug Administration’s approval of drugs for the treatment or prevention of gingivitis.1 In addition, the panel was concerned that studies of 3 months’ duration may show a benefit that may not be sustainable over a 6- to 12-month period. Dr. Graeber also challenged the selection of clinical attachment loss as the sole measure to assess treatment effectiveness. We agree that clinicians can use a variety of clinical, radiographic, and even microbiological outcomes to evaluate a patient’s response to therapy, and the expert panel considered a broad range of outcomes before selecting clinical attachment level (CAL) for its literature search. As discussed in our review, although probing depth is the primary diagnostic tool used in clinical practice, CAL is commonly reported in the scientific literature as a valid measurement of disease progression and has long been viewed as a primary therapeutic outcome by advisory groups and regulatory agencies, including the US Food and Drug Administration. Use of probing depth as the primary