Controversies in periodontics

1. CONTROVERSIES IN PERIODONTICS

2. What is usually read and written?

3. When a thing ceases to be a matter of controversy, it
ceases to be a matter of interest.
William Hazlitt (1778–1830)

4. Controversy vs Argument
Conflict Truth
Dogma

5. 10 Dogmas
1 Crevices >3mm are progressive lesions.
2 Sculpt gingiva and bone to the deepest defect to stop loss of support.
3 Complete plaque control by the patient is needed to stop periodontitis.
4 Furcation involvement signifies such poor prognosis.
5 The deeper the pockets, the poorer the prognosis.
6 The progress of advanced periodontal disease cannot be stopped by current treatments.
7 Healing after scaling and root planing is enhanced by soft tissue curettage.
8 Teeth with less than 7 mm of attached gingiva will continue to lose attachment.
9 Gingival blanching as a result of lip pull indicates need for mucogingival surgery.
10 Teeth with increased mobility after periodontal therapy should be splinted.

6. Therapies based on outdated dogmas
1 Periodontitis.
2 Disease prevention.
3 Diagnosis, prognosis and sequenced treatment planning.
4 Managing susceptible patients.
5 Non-evidence-based certain ‘adjunctive’ periodontal treatments .
6 Inappropriate decisions on periodontal referrals.
7 Lack of multidisciplinary management.
8 Low awareness in integration of oral and general health .

7. 2 Dogmas
1 ‘Periodontal overtreatment’ might compromise the possibility of
subsequent implant placement by ‘allowing’ the gradual loss of
supporting bone over the years.
2 By extracting teeth with periodontitis, the risk of reinfection and
peri-implantitis is supposed to be reduced.

8. Antczak-Bouckoms A. Natural history of periodontitis and a review of technologies to prevent and treat it. J Dent Educ. 1994 Aug;58(8):625-40.
Arguments
1How much and what type of evidence is needed?
One RCT=How many uncontrolled observations?
2Who bears the burden of proof?
All treatments are applied with the implicit assumption that they do more
good than harm.
Arguments

9. Controversy Argument
Dogma

10. Controversies in Periodontology
1 Ramfjord SP (1984)- Dogma’s in Periodontics
2 Robertson and DeRouen (2002)- Perio Care
3 Page & Sturdivant (2002)- NDPD
4 Lamont & Yilmaz (2002)- Bacterial pathogenesis
5 Schenkein (2002)- Host Susceptibility
6 O’Neal & Butler (2002)/Jin (2015)/ Pjetursson (2018)- Implants

11. Classification of controversy
1Cold controversy
Non-inflammatory destructive periodontal disease (NDPD)
2Past-controversy
Role of JE in periodontal health
3Boundless controversy
NSPT vs SPT, Periodontal medicine, GTR vs GTR+Graft
4Underground controversy
Classification of periodontal diseases
Marres N. Why Map Issues? On Controversy Analysis as a Digital Method. Sci Technol Human Values. 2015 Sep;40(5):655-686.

12. Classification of controversy
1 Controversies related to diagnosis
2 Controversies related to classification
3 Controversies in microbial aspects
4 Controversies in pathogenesis
5 Controversies in various treatment modalities
6 Controversies related to Implants
Jin LJ. Periodontal screening and management: The foundation of general dental practice. In Bartold PM, Chung KM (Eds) Periodontics: Beyond the Pocket.
Adelaide, Australia. Asian Pacific Society of Periodontology, 2010; 58-65.

13. Classification of controversy
1 Interdisciplinary treatment of periodontal patients.
2 Periodontology and Orthodontics.
3 Bone reconstruction in implant therapy.
4 Periodontal health and general health.
5 Periodontal health and endodontics.
6 Periimplantitis.
7 Mucogingival surgery of teeth.
8 Mucogingival surgery of implants.
Ion Zabalegui, Jorge Serrano, Laurence Adriaens & Andrés Pascual. Periodontology for dentists, benefits for patients
SPANISH SOCIETY OF PERIODONTOLOGY AND OSSEOINTEGRATION. Triennial report. 2016 | 2019.

14. Controversy on Interdisciplinary periodontics
Procedure Dogma & Controversy Resolution
Crown
Lengthening
Rebound more likely in
thick biotypes and
recession in thin biotypes*
1 – 3 months: Rebound likely
Routine
3 – 6 months: Aesthetics not critical
6 – 12+ months: Aesthetics are
critical**
Biologic Width Should not be encroached⁋ A self-corrected adaptation⁋⁋
“Biologic Zone”
“Periodontal
Prosthesis”
Ante’s Law
Structural Compromises
Lot of onus on splinting+
“SVI Rule”
• Stable
• Vital
• Intact++
Wyatt et al 2004;**Marzadori M. Periodontol 2000. 2018 Jun;77(1):84-92.
⁋Perez et al 2008, Barboza et al 2008; ⁋Fletcher P. Int J Periodontics Restorative Dent 2011;31:523–532.
+Kois & Spear, 1992; Liu. The Kaohsiung Journal of Medical Sciences.2018/02/01. 10.1016/j.kjms.2018.01.008.

15. Controversy on Ortho-Perio cases
Concept Dogma & Controversy Resolution
Ortho-in-Perio
cases
Orthodontics leads to
increased LOA & bone
loss*
“Osteotensoring”**
Mucogingival
Considerations
Gingival recession is a risk,
but augmentation must be
done after movement+
Mucogingival surgery prevents
recession when done before
orthodontic therapy++
Is Transseptal
Destruction
Necessary?
Ensure necessary
remodeling of the
transseptal fibers for
retention.!
Orthodontics movement induces
avascular necrosis which makes the
procedure redundant.!
*Melsen, 2001; **Binderman I., Scortecci G.M., Philip P., Choukroun J., Aalam AA. In: Scortecci G. (eds) Basal Implantology. Springer, Cham.
+Wennström, 1996++Laursen MG. Am J Orthod Dentofacial Orthop. 2020 Jan;157(1):29-34.
! Ardakani MR. Int J Dent Case Rep 2011;1:3-5.

16. Controversy on Bone reconstruction in implant therapy
Concept Dogma & Controversy Resolution
GBR Mechanical occlusion of
undesirable soft tissues*
“NBR”**
Will waiting
improve bone
fill and graft
incorporation?
Waiting for at least >8-
months+
“Mechanostat Theory”++
Type of graft Decision depends on the
characteristics of the
defect.!
“Foundation Concept”!!
*Retzepi & Donos 2010a; **Yu-Jin Jee. J Korean Assoc Oral Maxillofac Surg. 2019 Jun; 45(3): 121–122.
+Dimitriou R et al. BMC Med. 2011 May 31;9:66.++Amini AR et al. Crit Rev Biomed Eng . 2012 ; 40(5): 363–408.
! Christopher Ogunsalu (2011). ISBN: 978-953-307-481-8;!! Turchi JL. Dent Today. 2008 Jun;27(6):112, 114.

17. Controversy on Periodontal health and General health
1 “Sufficient Cause” for “Two-hits” missing
2 CVD: no definitive RCTs on
incident cardiovascular disease
3 DM: “Survivor” teeth or
Clinically healthy teeth?
4 APO: Which trimester?
Large interventions failed
RCTs are inconsistent

18. Controversy on Periodontal health and Endodontics.
Concept Dogma & Controversy Resolution
Independent/
Concomitant vs
Combined/
Coalesced
Based on the theoretic
pathways in Radiographs*
Nomenclature based on etiology or
treatment**
The effects of
endodontically
involved teeth
on Perio health
Mean PPD of a molar endo-
infection was 0.7mm
deeper+
Risk must be considered negligible
based on clinical outcomes.++
Perio-after-
Endo. Why?
Endodontic therapy only
will suffice.!
May be required in Combined or
Coalesced lesions!!
*Pathways of the Pulp. 8th ed. St. Louis: Mosby; 2002. p. 651-64. **Harrington GW, Steiner DR, Ammons WF. Periodontol 2000 2002;30:123-30.
+Jansson & Ehnevid, 1998++Harrington et al. Periodontology 2000, Vol. 30, 2002, 123–13.
! Solomon et al;!! Rosenberg et al.

19. Controversy on Periimplantitis.
Concept Dogma & Controversy Resolution
Surrogate
Endpoints for
Prediction of Fatal
Events
Improvement in Biologic
Markers would benefit
the patient*
They do not correlate with BOP and
PD and cause unnecessary alarmism
and overdiagnosis**
Periodontal
parameters to
Diagnose Peri-
Implant Disease
PPD≥6mm+
BOP +ve
PPD up to 9 mm in healthy implants.
PPD/BOP α Crestal bone loss
BOP α “Microgap” & Location++
Recommendations
from Consensus
Meetings
Periimplant mucositis is
reversible.
Periimplant mucositis is NOT
reversible at the histological level.!
* Faggion, C.M. J. Dent. 2010, 38, 443–450. ** Berglund T. J. Clin. Periodontol. 2018, 45 (Suppl. 20), S286–S291.
+ Choquet, V . J. Periodontol. 2001, 72, 1364–1371.++ Pierluigi Coli and Lars Sennerby. J. Clin. Med. 2019, 8, 1123; doi:10.3390/jcm8081123.
! Longo A. Fritz and Longo (2019) Clin Exp Dent Res. 1-6.

20. Controversy on Mucogingival surgery of teeth.
* Chambrone et al. Periodontology 2000. 2019;79:81–106.
* Kim DM et al. JPeriodontol. 2020;00:1–28.
When will
recession
coverage
be a regenerative
procedure?
* Chambrone et al. J Dent 2008;36:659-71.

21. Controversy on Mucogingival surgery of Implants.
Concept Teeth Implants
Minimum width of
gingiva
The requirement for a
minimum width of gingiva
around teeth is not
scientifically proven
A KM≥2mm is a must for implant
health*
Periodontal health
and gingival width
Periodontal health can be
maintained independent of
gingival width
A 2mm zone of KM is associated
with implant health, esthetics
and patient comfort**
Resistance to
attachment loss
A small band (<1mm) of
gingiva can have some
resistance to attachment loss
A KM band of less than 2mm will
result in soft tissue loss and
bone level loss in a 5-year
period***
*Monje A et al. J Periodontol. 2019 May;90(5):445-453.
**Bonino F et al.J Periodontol. 2018 Sep;89(9):1025-1032.
***David R. Cagna. September 2019Volume 122, Issue 3, Pages 198–269.

22. Mapping of controversy
Venturini, T. Diving in magma: How to explore controversies with actor-network theory. Public Understanding of Science, v. 19, n. 3, p. 258-273, 2010.
1. Non-controversial elements
2.Documentation
3. Analysis of scientific literature
4. Review of opinions
5. Tree of disagreement
5. Scale of controversies
6. Diagram of networks
7.Chronology of dispute
8. Table of controversies

23. “Controversy for the sake of controversy is sin.
Controversy for the sake of truth is a divine command.”

24. THANK YOU