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Die neue Richtlinie zur systematischen Behandlung von Parodontitis und anderen Parodontalerkrankungen
Abstract
Parodontitis ist neben Karies die epidemiologisch und versorgungsbezogen häufigste Erkrankung in der Zahnmedizin. Wird sie rechtzeitig erkannt, kann sie gut behandelt werden. Die Richtlinie, die bisher die systematische Therapie von Parodontopathien in der gesetzlichen Krankenver-sicherung geregelt hat, wies zahlreiche Inkonsistenzen und logische Brüche auf. Die Patientenvertretung im Gemeinsamen Bundesausschuss (G-BA) beantragte deshalb 2013, unterstützt von der Kassenzahnärztlichen Bundesvereinigung (KZBV), diese Regelungen auf wissenschaftliche Aktualität hin zu überprüfen. Nach Nutzenbewertung durch das Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen (IQWiG) und langen mühsamen Verhandlungen im G-BA ist Ende 2020 eine neue Richtlinie zur systematischen Behandlung von Parodontitis und anderen Parodontalerkrankungen (PAR-Richtlinie) beschlossen worden, die die gültige Klassifikation der Parodontalerkrankungen (2018) berücksichtigt und es erlaubt, die aktuelle (2020) evidenzbasierte klinische Leitlinie der European Federation of Periodontology (EFP) und der Deutschen Gesellschaft für Parodontologie (DG PARO) im Rahmen der Vorgaben einer ausreichenden, zweckmäßigen und wirtschaftlichen Versorgung umzusetzen.
Manuskripteingang: 25.03.2021, Annahme: 01.06.2021
Schlagwörter: PAR-Richtlinie, systematische Parodontitistherapie, Gemeinsamer Bundesausschuss (G-BA), Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen (IQWiG), strukturierte Nachsorge, Unterstützende Parodontitistherapie (UPT)
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Background:
COVID-19 is associated with an exacerbated inflammatory response that can result in fatal outcomes. Systemic inflammation is also a main characteristic of periodontitis. Therefore, we investigated the association of periodontitis with COVID-19 complications.
Methods:
A case-control study was performed using the national electronic health records of the State of Qatar between February and July 2020. Cases were defined as patients who suffered COVID-19 complications (death, ICU admissions or assisted ventilation), controls were COVID-19 patients discharged without major complications. Periodontal conditions were assessed using dental radiographs from the same database. Associations between periodontitis and COVID 19 complications were analyzed using logistic regression models adjusted for demographic, medical and behaviour factors.
Results:
In total, 568 patients were included. After adjusting for potential confounders, periodontitis was associated with COVID-19 complication including death (OR=8.81,95% CI 1.00-77.7), ICU admission (OR=3.54, 95% CI 1.39-9.05), and need for assisted ventilation (OR=4.57, 95% CI 1.19-17.4). Similarly, blood levels of white blood cells, D-dimer, and C Reactive Protein, were significantly higher in COVID-19 patients with periodontitis.
Conclusion:
Periodontitis was associated with higher risk of ICU admission, need for assisted ventilation and death of COVID-19 patients, and with increased blood levels of biomarkers linked to worse disease outcomes.
Background
The recently introduced 2017 World Workshop classification of periodontitis, incorporating stages and grades of disease, aims to link disease classification with approaches to prevention and treatment, as it not only describes disease severity and extent, but also the degree of complexity and an individual`s risk. There is, therefore, a need for evidence‐based clinical guidelines providing recommendations to treat periodontitis.
Aim
The objective of the current project was to develop a S3 Level Clinical Practice Guideline (CPG) for the treatment of stage I‐III periodontitis.
Material and Methods
This S3 CPG was developed under the auspices of the European Federation of Periodontology (EFP), following the methodological guidance of the Association of Scientific Medical Societies in Germany and the Grading of Recommendations Assessment, Development and Evaluation (GRADE). The rigorous and transparent process included synthesis of relevant research in 15 specifically commissioned systematic reviews, evaluation of the quality and strength of evidence, the formulation of specific recommendations and consensus, on those recommendations, by leading experts and a broad base of stakeholders.
Results
The S3 CPG approaches the treatment of periodontitis (stages I, II and III) using a pre‐established stepwise approach to therapy that, depending on the disease stage, should be incremental, each including different interventions. Consensus was achieved on recommendations covering different interventions, aimed at: i) behavioural changes, supragingival biofilm, gingival inflammation and risk factor control; ii) supra‐ and sub‐gingival instrumentation, with and without adjunctive therapies; iii) different types of periodontal surgical interventions; and iv) the necessary supportive periodontal care to extend benefits over time.
Conclusion
This S3 guideline informs clinical practice, health systems, policymakers and, indirectly, the public, on the available and most effective modalities to treat periodontitis and to maintain a healthy dentition for a lifetime, according to the available evidence at the time of publication.
It's about integrating individual clinical expertise and the best external evidenceEvidence based medicine, whose philosophical origins extend back to mid-19th century Paris and earlier, remains a hot topic for clinicians, public health practitioners, purchasers, planners, and the public. There are now frequent workshops in how to practice and teach it (one sponsored by the BMJ will be held in London on 24 April); undergraduate1 and postgraduate2 training programmes are incorporating it3 (or pondering how to do so); British centres for evidence based practice have been established or planned in adult medicine, child health, surgery, pathology, pharmacotherapy, nursing, general practice, and dentistry; the Cochrane Collaboration and Britain's Centre for Review and Dissemination in York are providing systematic reviews of the effects of health care; new evidence based practice journals are being launched; and it has become a common topic in the lay media. But enthusiasm has been mixed with some negative reaction.4 5 6 Criticism has ranged from evidence based medicine being old hat to it being a dangerous innovation, perpetrated by the arrogant to serve cost cutters and suppress clinical freedom. As evidence based medicine continues to evolve and adapt, now is a useful time to refine the discussion of what it is and what it is not.Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The …
This article reviews the key aspects of reducing the litigation aspects of the management of periodontal diseases and in particular periodontitis. Litigation arising from gingivitis, the other type of periodontal disease, is very rare and is therefore not considered in this article. This paper considers diagnosis, record keeping, communication, management of periodontitis including non-engaging patients and referrals. It provides guidance to reduce risks and improve the care for patients.
Die orale Lebensqualität (OLQ) kann durch Zahnverlust, Erkrankungen der Zahnhartsubstanzen wie Karies oder auch durch Symptome von Erkrankungen des Zahnhalteapparats wie erhöhte Zahnbeweglichkeit beeinträchtigt sein. Das Ziel der vorliegenden Übersichtsarbeit war, den Zusammenhang zwischen parodontalen Erkrankungen, gemessen an klinischen Parametern (Sondierungstiefe und klinischer Attachmentverlust), und der OLQ systematisch zu evaluieren. Es wurden 37 Studien in die Auswertung eingeschlossen. In 28 Publikationen konnte eine Beeinträchtigung der OLQ durch Parodontitis aufgezeigt werden. Zudem zeigten acht der eingeschlossenen Studien eine stärkere negative Beeinflussung der OLQ bei zunehmenden parodontalen Symptomen. Parodontitis ist demzufolge keine stille Erkrankung, sondern eine Erkrankung, welche die Lebensqualität des Patienten negativ beeinflusst.
Die vorliegende Arbeit basiert auf der englischen Publikation "Are periodontal diseases really silent? A systematic review of their effect on quality of life" (Buset et al. J Clin Periodontol 2016;43:333-344).
A classification scheme for periodontal and peri‐implant diseases and conditions is necessary for clinicians to properly diagnose and treat patients as well as for scientists to investigate etiology, pathogenesis, natural history, and treatment of the diseases and conditions. This paper summarizes the proceedings of the World Workshop on the Classification of Periodontal and Peri‐implant Diseases and Conditions. The workshop was co‐sponsored by the American Academy of Periodontology (AAP) and the European Federation of Periodontology (EFP) and included expert participants from all over the world. Planning for the conference, which was held in Chicago on November 9 to 11, 2017, began in early 2015.
An organizing committee from the AAP and EFP commissioned 19 review papers and four consensus reports covering relevant areas in periodontology and implant dentistry. The authors were charged with updating the 1999 classification of periodontal diseases and conditions1 and developing a similar scheme for peri‐implant diseases and conditions. Reviewers and workgroups were also asked to establish pertinent case definitions and to provide diagnostic criteria to aid clinicians in the use of the new classification. All findings and recommendations of the workshop were agreed to by consensus.
This introductory paper presents an overview for the new classification of periodontal and peri‐implant diseases and conditions, along with a condensed scheme for each of four workgroup sections, but readers are directed to the pertinent consensus reports and review papers for a thorough discussion of the rationale, criteria, and interpretation of the proposed classification. Changes to the 1999 classification are highlighted and discussed. Although the intent of the workshop was to base classification on the strongest available scientific evidence, lower level evidence and expert opinion were inevitably used whenever sufficient research data were unavailable.
The scope of this workshop was to align and update the classification scheme to the current understanding of periodontal and peri‐implant diseases and conditions. This introductory overview presents the schematic tables for the new classification of periodontal and peri‐implant diseases and conditions and briefly highlights changes made to the 1999 classification.1 It cannot present the wealth of information included in the reviews, case definition papers, and consensus reports that has guided the development of the new classification, and reference to the consensus and case definition papers is necessary to provide a thorough understanding of its use for either case management or scientific investigation. Therefore, it is strongly recommended that the reader use this overview as an introduction to these subjects. Accessing this publication online will allow the reader to use the links in this overview and the tables to view the source papers (Table 1).
Der vorliegende Beitrag geht der Frage nach, welche
Rolle der evidenzbasierten Medizin bzw. Zahnmedizin
(EbM/EbZ) bei der Einordnung und Bewertung
zahnärztlicher Leistungen zukommt bzw.
zukommen sollte und welche (weiteren) Mess- und
Einflussgrößen – gerade auch aus normativer Sicht
– in die Entscheidungsprozesse einbezogen werden
sollten. Grundlage des Beitrages ist die Auswertung
einschlägiger Fachbeiträge sowie eine diskursive Erörterung
der Potentiale und Grenzen der evidenzbasierten
Medizin unter besonderer Berücksichtigung
ethisch relevanter Aspekte.
Periodontal treatment consists of active periodontal therapy (APT) and supportive periodontal therapy (SPT). Regular SPT is recommended to prevent and control the occurrence of periodontal disease following APT. A patient's compliance with SPT is considered one of the most important factors affecting long-term periodontal status. Tooth loss is generally considered the final outcome of periodontitis. This review aimed to analyze the relationship between patient compliance with regular SPT and tooth loss. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guideline for systematic reviews was used. A search of articles was conducted using MEDLINE (PubMed) and other databases. Quality assessments of selected studies were performed. To assess the effect of compliance on tooth loss during SPT, pooled risk ratio of tooth loss (RRTL) was used as the primary outcome. Pooled risk difference of tooth loss (RDTL) and weighted mean difference of tooth loss rate (WDTLR) were used as secondary outcomes. Subgroup analysis and meta-regression were conducted to evaluate the effects of different variables. In total, 710 articles were screened. Eight studies, which had a regular-compliance (RC) group and an erratic-compliance (EC) group with at least a 5-y follow-up period, qualified for the meta-analysis. The risk of tooth loss in the RC group was significantly lower than that in the EC group (pooled RRTL: 0.56 [confidence interval (CI): 0.38, 0.82]; pooled RDTL: -0.05 [CI: -0.08, -0.01]). The definition of compliance was a variable significantly related to risk ratio of tooth loss. Patients in the RC group had significantly lower tooth loss rate during SPT than did patients in the EC group (WDTLR: -0.12 [CI: -0.19, -0.05]). Teeth have less risk of being lost if patients are more compliant with supportive periodontal therapy. However, unidentified variables causing data heterogeneity and affecting the risk of tooth loss may have been present. More well-controlled prospective studies are needed in the future.
© International & American Associations for Dental Research 2015.
Aimsto systematically review the evidence evaluating the efficacy of long-term, routine, professional mechanical plaque removal (PMPR) in the prevention of periodontitis progression.MethodsA literature search was conducted to identify prospective studies evaluating the effect of PMPR in periodontitis patients undergoing active periodontal therapy and enrolled in a maintenance program including PMPR for at least 3 years.ResultsNo RCTs evaluating the efficacy of the intervention when compared to no treatment during maintenance were found. Nineteen prospective studies assessing the effect of PMPR as part of the supportive therapy were included. In general, studies reported no to low incidence of tooth loss during follow-up. The weighted mean yearly rate of tooth loss was 0.15 ± 0.14 and 0.09 ± 0.08 for follow-up of 5 years or 12-14 years, respectively, with no significant differences between groups. Mean clinical attachment loss was < 1 mm at follow-up ranging from 5 to 12 years.Conclusions
Supportive therapy, which encompasses PMPR, may limit the incidence and yearly rate of tooth loss as well as the loss in clinical attachment in patients treated for periodontitis. However, whether and to what extent the intervention may impact on long-term periodontal parameters still needs to be assessed.This article is protected by copyright. All rights reserved.
Das Dilemma der Parodontitisnachsorge Individuen, die eine effektive individuelle Mundhy-giene betreiben, haben ein sehr geringes Risiko, eine Gingivitis oder ein Parodontitisrezidiv zu entwickeln. Setzt diese effektive Plaquekontrolle jedoch aus, werden die Zahnoberflächen schnell bakteriell besie-delt. Aus einer Situation klinischer Entzündungsfrei-heit entsteht nach einem Zeitraum von etwa drei Wochen ungehinderter Plaqueakkumulation eine manifeste Entzündung der Gingiva (plaqueinduzierte Gingivitis), und das nach systematischer Parodonti-tistherapie in den meisten Fällen etablierte epitheliale Attachment droht durch Umwandlung des Saumepi-thels in ein Taschenepithel wieder verloren zu gehen: Es kommt zu Attachmentverlusten und Taschenbil-dung. Es ist jedoch bekannt, dass bei Durchführung der unterstützenden Parodontitistherapie 1 in Abständen von drei Monaten die parodontalen Verhältnisse bei den meisten Patienten über lange Zeiträume stabil gehalten werden können 2 . Diese UPT-Frequenz führt aber in einer parodontologisch ausgerichteten Praxis mittelfristig dazu, dass ein Großteil der Behandlungs-kapazität im Recall gebunden wird und in letzter Konsequenz keine neuen Patienten aufgenommen werden können. Natürlich können nicht alle Patien-ten in der UPT gehalten werden: Sie bleiben weg, weil ihnen zum Beispiel die regelmäßigen Termine lästig sind und sie die Sinnhaftigkeit des Konzepts nicht begreifen oder weil sie durch besondere Lebensumstände (z. B. Krankheit, Pflegebedürftig-keit des Partners) andere Prioritäten setzen (man-gelnde Compliance). Das ungewollte Herausfallen von Patienten aus der UPT entlastet zwar die Praxis, kann aber nicht als strukturelles Element zur Erhal-tung der Funktionsfähigkeit einer parodontologisch ausgerichteten Praxis akzeptiert werden, weil es dem Konzept der lebenslangen Nachsorge ("Chroniker-programm") widerspricht. Im Idealfall sollten alle systematisch therapierten Patienten am Recall teil-nehmen und darin gehalten werden. Wie aber kann die UPT sinnvoll strukturiert werden, damit mehr Behandlungskapazität zur Verfügung steht? Zum einen können viele Inhalte der UPT an spe-ziell ausgebildetes Personal delegiert werden. Der Umfang der Tätigkeiten, die delegiert werden kön-nen, steigt mit dem Qualifikationsgrad der Mitarbei-ter: Prophylaxehelferin, ZMF, Dentalhygienikerin. Aber auch, wenn große Teile der UPT von weiterge-bildeten Mitarbeitern übernommen und so zusätzli-che Behandlungskapazitäten gewonnen werden, bleiben Behandlungsplatz und Zeit limitierende Fak-toren.
The concept of focal infection or systemic disease arising from infection of the teeth was generally accepted until the mid-20th century when it was dismissed because of lack of evidence. Subsequently, a largely silo approach was taken by the dental and medical professions. Over the past 20 years, however, a plethora of epidemiological, mechanistic and treatment studies have highlighted that this silo approach to oral and systemic diseases can no longer be sustained. While a number of systemic diseases have been linked to oral diseases, the weight of evidence from numerous studies conducted over this period, together with several systematic reviews and meta-analyses, supports an association between periodontitis and cardiovascular disease, and between periodontitis and diabetes. The association has also been supported by a number of biologically plausible mechanisms, including direct infection, systemic inflammation and molecular mimicry. Treatment studies have shown that periodontal treatment may have a small, but significant, systemic effect both on endothelial function and on glycemic control. Despite this, however, there is no direct evidence that periodontal treatment affects either cardiovascular or diabetic events. Nevertheless, over the past 20 years we have learnt that the mouth is an integral part of the body and that the medical and dental professions need to work more closely together in the provision of overall health care for all patients.
Abstract 116 subjects were recruited from a population of patients previously treated for adult periodontitis and maintained in periodontal health by means of periodic prophylaxes every 3–6 months. The subjects were divided into a control (C) and a test (T) group. A total of 33 patients in the T group and 47 in the C group completed the 4-year study. The C subjects were examined every 6 months and given a prophylaxis every 3 months. The patients in the T group were examined at similar intervals, but prophylaxes were administered according to the individualized scheme of Listgarten and Shiffter, on the basis of a differential microscopic count of subgingival bacterial morphotypes. Recurrent periodontitis was defined as an increase in probing depth of 3 mm or more from baseline measurements. Teeth so affected were sampled microbiologically when the diagnosis of recurrent disease was made and “exited” from the study for treatment. A control microbial sample was taken at the same time from a previously-defined pooled sample of non-affected surfaces with comparatively high, but stable probing depths. During a 4-year period, more than half of the subjects developed at least one recurrence of disease, and one-third of the subjects had 2 or more recurrences of periodontitis. Disease recurred on approximal surfaces 81% and on oro-vestibular surfaces 19% of the time. There were no significant differences in the rate of disease recurrence between the C and the T group, even though recall intervals in the T group at the 4-year examination averaged 19.4 months and an average of 30.6 months had elapsed since the previous prophylaxis. Both groups exhibited similar plaque index and gingival index scores, similar probing depth and attachment level measurements, and similar proportions of different bacterial morphotypes during the 4-year study. However, differences were noted between examinations for both groups with respect to most of these criteria. This study provides 4-year longitudinal data on the clinical and certain microbiological characteristics of a population of adult patients previously treated for moderate to advanced periodontitis, and subsequently placed on periodontal maintenance. The results indicate that some of these patients may remain in good periodontal health despite the lack of regular tri-monthly recall visits, and that microscopic monitoring of the subgingival microbiota may be of value in identifying these individuals. Our findings also indicate that microscopic monitoring of the subgingival microbiota may not provide sufficient benefits to justify the additional time and labor required to incorporate this technique into a standard regimen of periodontal preventive maintenance.
To evaluate an individually tailored oral health educational programme (ITOHEP) on periodontal health compared with a standard oral health educational programme. A further aim was to evaluate whether both interventions had a clinically significant effect on non-surgical periodontal treatment at 12-month follow-up.
A randomized, evaluator-blinded, controlled trial with 113 subjects (60 females and 53 males) randomly allocated into two different active treatments was used. ITOHEP was based on cognitive behavioural principles and motivational interviewing. The control condition was standard oral hygiene education (ST). The effect on bleeding on probing (BoP), periodontal pocket depth, "pocket closure" i.e. percentage of periodontal pocket >4 mm before treatment that were <5 mm after treatment, oral hygiene [plaque indices (PlI)], and participants' global rating of oral health was evaluated. Preset criteria for PlI, BoP, and "pocket closure" were used to describe clinically significant non-surgical periodontal treatment success.
The ITOHEP group had lower BoP scores 12-month post-treatment (95% confidence interval: 5-15, p<0.001) than the ST group. No difference between the two groups was observed for "pocket closure" and reduction of periodontal pocket depth. More individuals in the ITOHEP group reached a level of treatment success. Lower PlI scores at baseline and ITOHEP intervention gave higher odds of treatment success.
ITOHEP intervention in combination with scaling is preferable to the ST programme in non-surgical periodontal treatment.
To assess periodontitis-related knowledge and its relation to oral health behaviour on a community level and to identify target groups and major topics for health education interventions.
By means of a multistratified, stochastic telephone survey, 1001 interviews with Germans older than 14 years were carried out. Participants answered questions on the definition, aetiology, and risk factors of periodontal disease and on the risks associated with and measures to prevent them. They also reported on their current oral health behaviour.
Severe knowledge deficits were found with respect to all topics. No consistent relationships with age or education were found, although less educated and very young and old people tended to show the greatest deficits. Knowledge of preventive measures was most strongly related to current oral health behaviour.
Health education on periodontal diseases must be improved on a community level, although schoolchildren, older citizens and the less educated are the groups most in need. Interventions should focus on preventive measures.
Abstract The investigation was undertaken to find out whether favourable conditions for healing after periodontal surgery would develop in patients whose oral hygiene was professionally maintained at a high standard. The study was performed on 20 patients with advanced periodontal disease. Following an initial examination, comprising plaque index and gingival index scoring, measurement of pocket depths and loss of attachment, the patients were randomly distributed between a test and a control group. The patients first received detailed instructions for oral hygiene and were then subjected to periodontal surgery with the reverse bevel flap procedure. After surgery, the patients of the test group received professional cleaning of the teeth once every 2 weeks. The patients of the control group were recalled for scaling of the teeth once every 6 months. All patients were re-examined after 6, 12 and 24 months.
It was found that the control patients were unable to maintain a high standard of oral hygiene with the result that the treatment of the periodontal disease failed. The patients of the test group maintained a high standard of oral hygiene, and the treatment of the periodontal disease was, therefore, successful.
The present investigation was performed to assess the efficacy of a maintenance care program to prevent recurrence of disease in patients subjected to treatment of advanced periodontitis. In addition, the periodontal status was monitored of a group of patients who following the end of active treatment were referred back to genera] practitioners for maintenance care. The material consisted of 90 patients who in 1972 were referred for specialist treatment of advanced periodontal disease. The patients were first subjected to an initial examination including assessment of oral hygiene, gingivitis, probing depths and attachment levels. They were on an individual basis given case presentation, instructed how to practice proper tooth-cleaning methods, their teeth were scaled and eventually the periodontal pockets were treated using the modified Widman technique. During the first 2 months following surgery the patients were recalled once every 2 weeks for professional tooth cleaning. Two months after the end of surgical treatment, the patients were reexamined to provide baseline data. Every third patient was thereafter referred back to the general dentist for maintenance care. Two out of three patients were maintained in a carefully designed and controlled maintenance care program at the university clinic. This program involved recalls once every 2–3 months and included instruction and practice in oral hygiene, meticulous scaling and professional tooth cleaning. The patients were reexamined 3 and 6 years after the baseline examination.
Assessment of patient-related factors contributing (1) to tooth loss and (2) to the quality of treatment outcome 10 years after initiation of anti-infective therapy.
All patients who had received active periodontal treatment 10 years ago by the same examiner were recruited consecutively until a total of 100 patients were re-examined. Re-examination was performed by a second examiner and included clinical examination, test for interleukin-1 (IL-1) polymorphism, smoking history, review of patients' files (e.g. regularity of supportive periodontal therapy: SPT). Statistical analysis included Poisson and logistic regressions.
Fifty-three patients attended SPT regularly, 59 were females, 38 were IL-1 positive. Poisson regressions identified mean plaque index during SPT (p<0.0001), irregular attendance of SPT (p<0.0001), age (p<0.0001), initial diagnosis (p=0.0005), IL-1 polymorphism (p=0.0007), smoking (p=0.0053), and sex (p=0.0487) as factors significantly contributing to tooth loss. Additionally, mean plaque index during SPT (p=0.011) and irregular SPT (p=0.002) were associated with a worse periodontal status 10 years after initiation of therapy.
The following risk factors for tooth loss were identified: ineffective oral hygiene, irregular SPT, IL-1 polymorphism, initial diagnosis, smoking, age and sex.
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