Evidence-based periodontology

1. Evidence Based Periodontology
PRESENTED BY
SUMA APPAM

2. CONTENTS
• Introduction
• What is evidence-based periodontology
• Development of evidence-based periodontology
• Components of evidence-based periodontology
• Evidence based periodontology versus
traditional periodontology
• Advantages of evidence-based periodontology
• What is PICO?
• Searching evidence
• Evidence based approach in periodontal
therapy.
• Review of clinical points
• Conclusion

3. Sackett et al 1996, Philips 2010
• What it is evidence ??
• What is EBM?
Evidenced based medicine is conscientious, explicit, and judicious
use of current best evidence in decisions about the care of
individual patients.

4. Evidence based dentistry
• According to American Dental Associations definition
“Evidence based dental practice is the integration of an
individual practitioner’s experience and expertise, with a
critical appraisal of relevant available external clinical
evidence from systematic research, and with consideration
for the patient’s needs and preferences”. This definition
stresses the importance of 3 elements.
• Dentist expertise and clinical Judgment.
• Relevant clinical evidence that is present in literature.
• Informed patient’s preference

5. • A systematic practice of dentistry in which the dentist finds, assess and
implements methods of diagnosis and treatment on the basis of the best
available current research, their clinical expertise and the needs and preferences
of the patient.
- Mosbys medical dictionary

6. Why is evidence-based dentistry required?
• Encourages the dentist to look for evidence available and apply to everyday
clinical problems.
• Enable high quality, clinically oriented and relevant research to be applied.
• Better information to clinician.
• Improved treatment to patient.
• Reduce variation in patient care.
• Increased standing of the profession.

7. DEVOLOPMENT OF EVIDENCE BASED
PERIODONTOLOGY
• EBP is built upon developments in clinical research design throughout the18th, 19th
and 20th centuries.
• Evidence-based medicine has only been known for just over a decade and the term was
coined by the Clinical epidemiology group at McMaster University in Canada.
• One of the earliest to take up the challenge in periodontology (in fact in oral health
research overall) was Alexia Antczak Bouckoms in Boston, USA.

8. Alexia Antczak Bouckoms set up an Oral
Health Group as part of the Cochrane
Collaboration.
1994
World Workshop in Periodontology held
by the American Academy of
Periodontology which included
elements of evidence-based healthcare,
supported by Michael Newman at UCLA.
1996
The editorial base of the Oral Health
group subsequently moved to
Manchester University with Bill Shaw
and Helen Worthington as co-
ordinating editors.
1997
The first Cochrane systematic review in
periodontology was published and
researched the effect of guided tissue
regeneration for infrabony defects
2001
European workshop on periodontology.
The workshop was organized by the
European Academy of Periodontology
for the European Federation of
Periodontology
2002

9. • 2003 : Contemporary Science Workshop by the American Academy of
Periodontology Many other groups are now using similar methods in
healthcare and research.
• 2003 : International Center for Evidence-Based Oral Health was launched
(http://www.eastman.ucl.ac.uk/ iceboh) to produce high quality evidence-
based research with an emphasis on, but not limited to, periodontology
and implants and to provide generic training in systematic reviews and
research methods.

10. What is evidence-based periodontology?
• Is the application of evidence-
based health care to
periodontology.
“An approach to decision making
in which the clinician uses the
best evidence available, in
consultation with the patient, to
decide upon the option which
suits that patient best.”
Muir Gray JA. Evidence-based, locally owned, patient-centered guideline development. Br J Surg; 1997;84:1636-7

11. What Evidence Based Periodontology is not ?
Is not simply systematic reviews of randomized controlled trials
 Is an approach to patient-care and nothing more. so, the expectations
that are sometimes laid on it can be inappropriate.
It cannot provide answers if research data do not exist
It cannot substitute for highly developed clinical skills.
Therefore, it can never be cookbook healthcare or use statistics in
isolation to drive clinical care.

12. Evidence-Based
Periodontology
vs. Traditional
Periodontology

13. Components of
evidence-based
periodontology
Needleman I, Moles D R,
Worthington H. Evidence-
based periodontology,
systematic reviews and
research quality. Periodontol
2000 2005; 37:12–28

14. The NNT(number needed to treat) is the average number
of patients who need to be treated to prevent one
additional bad outcome.
NNT
achieve avoid
NNTb NNTh
•It is defined as the inverse of the Absolute risk
reduction.(ARR)
•It was described in 1988.

15. Why the
evidence-based
approach is
better than other
assessment
methods ?
It is objective.
It is scientifically sound.
It is patient focused.
It incorporates clinical experience.
It stresses on good judgement.
It is thorough and comprehensive.
It uses transparent methodology.

16. Advantages of evidence-based periodontology
• By evaluating the scientific data ,to minimize the faults for the final diagnosis, to reduce
the wrong diagnosis possibility.
• To choose the best treatment for the patient.
• To decrease cost and time of the treatment ,accordingly, contributing to the national
economy.
• Increasing the knowledge and experience due to an extensive literature surveillance by
the clinicians.
• Will serve patients better only tested procedures will be endorsed.
• To increase the patient satisfaction.
• To decrease the legal liabilities of the doctors.

17. Terminologies used in Evidence Based Approach
• SYSTEMATIC REVIEW: Review of a clearly formulated question that attempts to minimize bias using
systematic and explicit methods to identify, select, critically appraise and summarize relevant research.
• INTERPRETATION: It is the process by which qualitative methods seek to identify subjective meaning of
a phenomenon.
• INTERACTION: Encounter between physician and patient helps in bringing together conflicting views of
health and illness.
• BIAS: Is a system up with the relative error leads to results which are consistently wrong.
• CONFOUNDING: Describes the situation where an estimate of the association between an exposure and the
disease is mixed up with the real effect of another exposure on the same disease,the two exposures being the
same.

18. • Odds ratio: Ratio of exposure among cases to exposure among controls.
• Randamization

19. Evidence-Based
Decision Making
Integrating the
Most Current
Knowledge
into Clinical
Decision Making

20. Develop into
a focused
question
Forrest JL, Miller SA, Newman MG : Introduction to evidence – based decision making. In
Newman, Takei, Klokkevold, Ferman A. Carranza: Clinical periodontology, 10th edition,
WB Saunders and company, 2009, chapter 1 (12 – 21)
• Converting information needs and problems into
clinical questions is a difficult skill to learn, but is a
fundamental to evidence based practice.
• A well built question should include 4 parts:
• Patient problem or population
• Intervention / Exposure
• Comparison
• Outcome

22. Framing the question:
 clinician to focus on what he and patient believes
Identify key terms for computerized search.
Easy identification of:
a) Problems, results ,outcome.
b) Types of evidence and information required.
Determine effectiveness of intervention and application
Increase chances of finding the answer.

23. In patients with periodontal disease, will
short-term systemic antibiotics, when
compared to surgery, reduce pocket depth?
Population
intervention
comparison
outcome
Scenario 1

24. Scenario 2
Clinical Situation
 Adult female patient presents
with heavy plaque and gingivitis
and is considering changing
from a manual to a power
toothbrush.
Step 1. PICO Question
 For patients with heavy plaque
and gingivitis (P), will a power
toothbrush (I), as compared to a
manual brush (C), result in
greater reductions in plaque
and gingivitis(O)?
24

25. Özkan Y, Orbak R (2016) The Evidence-Based Periodontology. JSM
Dent 4(5): 1075.

26. Animal and Laboratory Studies
Case Report or Case Series
Narrative Reviews, Expert Opinions, Editorials
Case Control Studies
Cohort Studies
Randomized
Controlled Trials
META-ANALYSES
Systematic Reviews
Hierarchy of evidence 26
HIGHEST
LOWEST

27. Searching for evidence

28. The Information Explosion
• Number of internet devices in:
• Number of years it took TV to reach market an audience of 50
million:
• Number of years it took the Internet to reach a market audience
of 50 million
• Number of years it took the iPod to reach a market audience of
50 million:

29. Number of internet devices in:
1984:
1992 1,000,000
2008:
2010: 5,000,000,000
2020: 50,000,000,000
1,000,000,000
1,000
29

30. The Information Explosion
Number of years it took to reach a
market audience of 50 million:
2 years
30
searches per month
In 2006: 2.7 billion
In 2008: 31 billion
In 2010: 88 billion
In 2015: 115 billion
2019-3.5 billion searches per day
Google Serves 11 Million Fact Checked
Articles Per Day - Search Engine Journal. 2019

31. Primary source
•original research publications
that have not been filtered or
synthesized.
•Available online :electronic
journals
Secondary source
primary literature.
•Includes:
Systematic reviews
Meta analyses
Evidence-based article reviews
clinical practice guidelines
protocols.
•synthesized publications of the

32. • PubMed Clinical Queries: Find Systematic Reviews
http://www.ncbi.nlm.nih.gov/sites/pubmedutils/clinical
• Cochrane Library (Published by Wiley InterScience)
http://www3.interscience.wiley.com/cgi-bin/mrwhome/106568753/HOME
• ADA Website: Systematic Reviews & Summaries/ Clinical Recommendations
http://ebd.ada.org/SystematicReviews.aspx

33. Other biomedical databases are: MEDLINE
EMBASE HEALTH
STAR CINALH
COCHRANECOLLABARATIONLIBRARY
Sciencedirect

34. 34

35. This page provides the
following specialized
PubMed searches for
clinicians.
Starting Point
35

36. Find Systematic Reviews Feature
36

37. 37

38. Click here to
get the Full Text
Online
Step 3. Critical Analysis of the Evidence
38

39. http://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD002281/frame.html
39

40. http://www3.interscience.wiley.com/cgi-bin/mrwhome/106568753/HOME?CRETRY=1&SRETRY=0
40

41. doi

42. COCHRANE COLLABORATION
Many health care journals now published systematic reviews, but the best known source isThe Cochrane
Collaboration, a group of over15,000 specialists in health care who systematically review randomized
trials of the effects of treatments, and when appropriate, the results of other research.
Cochrane reviews are published in The Cochrane Database Of Systematic Reviews section of The
Cochrane Library, which upto January 2009 contained 3,625 complete reviews and 1,921 protocols for
additional reviews being conducted.
42

43. Sources of Systematic Reviews and Meta-Analyses
43

44. Systematic review
 A systematic review is a literature review focused on a single question that tries to identify,
appraise, select and synthesize all the high-quality research evidence relevant to that question.
 A review of a clearly formulated question that attempts to minimize bias using systematic and
explicit methods to identify, select, critically appraise and summarize relevant research.
Systematic reviews of high quality RCT are crucial to EBP

45. OBJECTIVES OF SYSTEMATIC REVIEWS
• To provide a comprehensive and contemporary appraisal of research using transparent methods
while aiming to minimize the bias.
• To aid in clinical decision making.
45

46. WHAT A HIGH QUALITY SR CANDO
• Find and summarize all the available studies.
• Provide an assessment of the quality of the research and in particular the degree of protection from bias within
the original studies.
• Estimate research effects across the multiple studies with meta-analysis.
• It is possible to generalize the results if the effect is consistent across multiple studies.
CANNOT DO
• Cannot be used in isolation to dictate clinical practice.
• Can only be used in context with clinical judgment and patient preference.
• Cannot give strong conclusions if the research base is weak in quality.
• Cannot overcome limitations of narrowly designed clinical research.
18• Cannot exclude irrelevant studies.
Evidence-based periodontology, systematic reviews and research quality IAN NEEDLEMAN et al perio 2000, vol 37 , 2005

47. Research methodology
Multiple studies
Pool data
Derive a focused question Address
a particular hypothesis.
Research synthesis

48. QUALITY ASSESSMENT CHECKLIST FOR SYSTEMATIC REVIEWS IN DENTISTRY
48

49. COMPARISON OF CHARACTERISTICS OF SYSTEMATIC REVIEWS AND TRADITIONALLITERATURE
REVIEWS
CHARACTERISTIC SYSTEMATIC REVIEW LITERATURE REVIEW
Focus of review Specific problem : Narrow focus.
Eg : Effectiveness of Periostat as an
adjunct to scaling and root planing for the
treatment of adult periodontitis.
Range of issues on a topic:
Broad focus.
Eg : Effectiveness of adjunctive
antimicrobial agents for treating
periodontitis.
Who conducts Multidisciplinary team Individual
Selection of studies to
include
Pre-established criteria based on validity
of the study design and specific problem;
All studies that meet the criteria are
included.
Criteria not pre-established or
reported in the methods;search on
range of issues.may include or
exclude studies based on personal
bias or support for the hypothesis,if
one is stated.
23

50. CHARACTERISTIC SYSTEMATIC REVIEW LITERATURE REVIEW
Reported findings Search strategy: databases searched.
Number of studies that met or did not
meet the criteria: why certain studies were
excluded.
Description of study design, subjects,
length of trial,state of health /
disease,outcome measures.
Literature presentation format
crafted by the individual author.
Search strategy,databases and
total number of studies(pros and
cons)are rarely identified.
Descriptive in nature, reporting
the outcomes of studies rather
than their study design.
Synthesis of selected
studies
Critical analysis of the included studies.
Determination of the results could be
statistically combined.
Reporting of studies that support a
procedure or position and those that
do not;rather than combining data or
conducting a statistical analysis.
50

51. CHARACTERISTIC SYSTEMATIC REVIEW LITERATURE REVIEW
Main results Summary of trials;
Total number of subjects.
Definitive statements about findings in
relation to objectives and outcome
measures
Summary of the findings by the
authors in relation to the purpose
of literature review and specific
objectives.
Conclusions or
comments
Discussion of key findings with the
interpretation of the results, including
potential biases and recommendations
for future trials.
Discussion of key findings with
the interpretation of the results,
including recommendations and
limitations for future trials.
51

52. META-ANALYSIS
DEFINITION: by Huque
“ A statistical analysis that combines or integrates the results of several independent clinical trials
considered by the analyst to be ‘combinable’.
“ statistical overview”, “quantitative synthesis” , “pooling” and “weighted averaging” .
52
The term coined in 1976by the psychologist Glass .
• The first meta-analysis has been identified as the 1940 book-length publication “Extra- Sensory
Perception after 60 years”, J.G.Pratt et al
• The meta-analysis of a medical treatment was first published in 1955.
• In oral health care, the first meta-analysis indexed in the MEDLINE database was published in 1989 .

53. TYPES OFMETA-ANALYSIS
POOLED ( QUANTITATIVE ) ANALYSIS :
• The analysts pool the observations of many studies and then calculate parameters such as risk ratios
or odds ratios from the pooled data. ( Grebarg and Horowitz,1988 )
• Pooled analysis should report both relative risk and reductions and absolute risk and risk reductions.
METHODOLOGIC (QUALITATIVE ) ANALYSIS:
• The quality of the research concerning the intervention is scored according to a list of objective
criteria.
• The analyst then examines the methodological superior studies to determine whether or not the
question of benefits is answered correctly by them.
• termed methodological analysis ( Grebarg and Horowitz, 1988 ) or ‘ quality scores analysis’
(Greenland, 1994 ).
• In some cases, the methodologically strongest studies agree with one another and disagree with the
weaker studies, which may or may not be consistent with one another.
53

54. Experimental studies:
Randomized-controlled trial: parallel group design
– a group of participants (or other unit of analysis,
e.g. teeth) is randomized into different treatment groups.
These groups are followed up for the outcomes of interest.
Randomized-controlled trial: split-mouth design
– each patient is his/her own control. A pair of similar teeth, or
groups of teeth (quadrants), may be selected and randomly
allocated to different treatment groups.
Non-randomized controlled trial – allocation of participants under
the control of the investigator, but the method falls short of genuine
randomization.
Different study designs

55.  Cohort: a longitudinal study, identifying groups of participants according to their
exposure/intervention status. Groups are followed forward in time to measure the
development of different outcomes.
Case-Control: a study that identifies groups of participants according to their
disease/outcome status. Groups are investigated/ questioned to determine their
exposure status.
Cross-sectional: a study (survey) undertaken on a defined population at a single point in
time (snap-shot). Subjects are observed on just one occasion and are not followed up.
Observational studies

58. some evidence is better than other evidence,
greater emphasis on good than on poor quality evidence
when making clinical decisions.
How exactly we decide what constitutes
good quality evidence. This process is
critical appraisal.

59. Internal validity
•Focuses on the
methodology of
research
External validity
•can the findings
be generalized
outside of the
study

60. The validity of published evidence is potentially
affected by the quality of every stage of the
experimental process from:
 aims and objectives,
 design,
 execution,
 analysis,
 interpretation,
 and finally publication

61. Evidence needs to be
critically appraised.
 Quality of evidence may vary according to the study design.
 The publication of the results in a high ranking journal is not an absolute guarantee of quality.
CRITICAL APPRAISAL

62. Outcome will be
effected by:
bias
Confounding
chance

63. BIAS
• Bias is any systematic error in design, conduct or analysis of a study which leads to an erroneous
conclusion ( Soben Peter )
• Bias leads to an incorrect estimate of the effect of a risk factor or exposure on the development of
a disease or outcome.
• The observed effect will be either above or below the true value.
TYPES OF BIAS
1. SELECTION BIAS ( How the subjects were selected for inclusion in the study?)
2. PERFORMANCE BIAS ( Provision of care )
3. DETECTION / MEASUREMENT BIAS (Assessment of outcomes)
4. PUBLICATION BIAS

64. CONFOUNDING
• Term that describes the situation where an estimate of the association between an
exposure and the disease is mixed up with the real effect of another exposure on the
same disease, the two exposures being correlated.
Coffee drinking
Poor treatment
response
Smoking
habits
(confounder)
Risk factorAssociation
Evidence-based periodontology, systematic reviews and research quality IAN NEEDLEMAN et al perio 2000, vol 37 , 2005

65. Confounding can be dealt with at the design stage of the investigationby:-
1. RANDOMIZATION
2. RESTRICTION
3. MATCHING

66. CHANCE
• Chance is a random sampling error.
• The extent to which the sample results reflect the likely result in the population is assessed by
performing statistical significance tests , and more importantly, by calculating the confidence
intervals.
INTERPRETATION
• The authors may also fail to interpret their experimental results correctly. So, even if the study has
been well conducted and appropriately analyzed , there is still the potential to draw incorrect
conclusions from the results

68. While acknowledging the limitations of the current status in evidence‐based clinical practice, it is
imperative that periodontists move ahead and address barriers to implementation. For example, one of
the major limitations is lack of high‐quality evidence in some of the most fundamental aspects of
periodontology, such as flossing and supportive periodontal maintenance therapy. Conduct of
high‐quality research is the first step.
Then, dissemination of already available high‐quality evidence through multiple means must be adopted
to suit local settings. Finally, a multipronged approach to educate periodontists to adopt and implement
high‐quality evidence should be undertaken. Implementation studies to evaluate the effectiveness of this
process would be necessary.

69. Evidence - based approach in periodontal
therapy
• EBA and mechanical nonsurgical pocket therapy.
• EBA on systemic antibiotics
• EBA on LDD
• EBA on Effect of smoking on NST.
• EBA in periodontal regeneration.
• EBA and mucogingival surgery.
• EBA on SPT
• EBA on periodontal progenitors
• EBA on dental implants.

70. Evidence - based approach and mechanical
nonsurgical pocket therapy
• Non-surgical periodontal therapy includes both mechanical and chemotherapeutic
methods of controlling plaque and reducing inflammation. The benefits of mechanical
instrumentation have been demonstrated in a myriad of longitudinal, cohort and
randomized clinical trials. Demonstrated benefits of scaling and root planing include
decreased gingival inflammation, decreased probing depth and maintenance of clinical
attachment level. The evidence indicates that similar results may be obtained with
ultrasonic and sonic instruments and manual instruments.
• A total of 9 reviews were searched for the best evidence. NST was found to have a
positive effect with the exception of pockets < 3mm.
• No difference was found between the effect of hand- driven and machine-driven
instruments. Machine driven instruments were faster than hand-driven instruments.

71. • The various antiplaque and/or antigingivitis agents don’t offer substantial benefit
for treatment of periodontitis.
• They may however contribute to the control of gingival inflammation that exists
with periodontitis.
• Supragingival irrigation may be used as an adjunct to tooth brushing and aid in
the reduction of gingival inflammation.
• Even when subgingival irrigation is used, the evidence shows that there are no
clear substantial long-term benefits for the treatment of periodontitis.
• Now it has become an important part of clinician’s armamentarium. The magnitude of
gingival inflammation was greatest for chlorhexidine. The evidence supporting these
results has come from multiple randomized double blind; controlled clinical trails.

72. Antibiotic therapy and Periodontics
• The risk benefit ratio indicates that systemic antibiotics should not be used
for the treatment of gingivitis and common forms of adult periodontitis.
• But evidence suggests that systemic antibiotics may be useful in aggressive
forms of periodontitis.

73. • Optimal dose and duration of amoxicillin‐plus‐metronidazole as an adjunct to
non‐surgical periodontal therapy: A systematic review and meta-analysis-2017
• There was no clinically meaningful difference between different doses or duration
of amoxicillin‐plus‐metronidazole at 3 months post‐treatment. Without compelling
evidence to suggest that any one regimen performed superiorly, principles of
responsible antibiotic use generally recommend the highest dose for the shortest
duration of time to reduce the risk of antibiotic resistance. Therefore, a 7‐day
regimen of 500/500 mg or 500/400 mg of amoxicillin and metronidazole would be
most appropriate.
• Adjunctive systemic amoxicillin and metronidazole medication to SRP
significantly improved the clinical outcomes with respect to mean PD, CAL and
BOP compared to SRP alone in chronic periodontitis patients. (2016)

74. Evidence on
LDD
• Local delivery drug systems are seemingly a good
alternative to deliver antimicrobial agents compared to
systemic delivery.
• There was modest gain in clinical attachment level and
decrease in probing depth and gingival bleeding.
• They produce fewer side effects, namely, transient
discomfort, erythema, recession, allergy, and rarely,
candida infection.
• which could improve patient compliance. Since there are
no studies proving the effective use of locally delivered
drugs as a monotherapy, local drug delivery system
remains to be a good adjunct therapy.
• Conclusion: adjunctive therapies continued to be
explored, mechanical debridement is still the single best
option available. It remains the foundation treatment for
many adjunctive antimicrobial treatment investigations.

75. Effect of smoking on NST
• Systematic review of the effect of smoking on NST was conducted by Labriola etal (2000) .
Search strategy included Medline, Embase and Central. Study designed was controlled clinical trial.
Outcomes :
• There was reduced pocket depth reduction in smokers, compared with non -smokers.
• no significant difference in the change of Clinical Attachment Level (CAL) between smokers and
nonsmokers.
• The reason could be that the increased vasoconstriction in peripheral blood vessels of smokers leads to
decrease in bleeding and edema. Also, smokers would have less potential for resolution of inflammation and
edema within the marginal tissues and therefore less potential for gingival recession.

76. EBA in periodontal regeneration
• They are designed to facilitate growth of new periodontal ligament, cementum and
bone over previously diseased root surface. There are a wide variety of
regeneration techniques including bone grafts and guided tissue regeneration.

77. Grafting procedures
Meta-analysis was done by Reynolds et al (2003) and Trombelli et al (2002).
Short-term changes(12 months after intervention)
 Autogenous bone: Trombelli et al : greater CAL gain but not
statistically significant.
Reynolds et al :statistically signifcant gain in CAL
 Bone allograft: gain in CAL, and increased defect fill,PPD reduction
 Dentin allograft: a gain in CAL
 Coralline calcium carbonate: a gain in CAL and bone fill but no improvement in
pocket depth reduction.
 Bioactive glass: improvement of bony lesion when compared with open flap
debridement [OFD]
 Porous/nonporous hydroxyapatite:(PMMA)and (PHEMA)
Polylactic acid granules:gain in CAL and decrease in probing pocket depth.

78. • No evidence was found for difference in the use of ePTFE versus bio-resorbable
membranes.
• Long term clinical outcomes / patient centered outcomes could not be
determined due to lack of available data.

79. Guided tissue
regeneration (GTR)
• Guided tissue regeneration These procedures used physiological barriers
or membrane to facilitate selective population of the root surface by cells
capable of forming new tissues.
• The goal of membrane is to exclude the epithelial cells from the surface
while maintaining a space in to which periodontal cells can grow.
Investigators have studied both resorbable and non-resorbable
membranes. While less evidence is available for resorbable membrane
than for non-resorbable membranes.

80. • Recently, two systematic reviews have been published assessing the efficacy of
GTR in the treatment of intra osseous defects with respect to open flap
debridement (Murphy 2003 and Needlemen 2001) The results of the review are
• 1. GTR produces an additional clinical attachment gain, probing depth reduction
and defect fill when compared to open flap debridement
• 2. Limited number of studies have shown that additional effect of the
combination treatment, (GTR+BONE substitutes) is similar to GTR alone
• 3. The addition of bone substitute and membrane does not produce any
adjunctive effect compare to the use of the membrane alone

81. EBA and mucogingival surgery
• Critical review by Pagliaro(2003): on surgical therapy led to the following
conclusions:
• The overall clinical outcome of different techniques appears to be satisfactory,
but the great variability among different studies creates difficulties in deciding
which procedure is best suited for each clinical situation.
• The data are quite heterogeneous.

82. Carlo Clauser (2003)
in his meta-analysis found that
• All the surgical procedures allow complete root coverage.
• Connective tissue grafting achieves complete root coverage more frequently
than does GTR.
• The probability of complete root coverage is high if the initial recession is
shallow, irrespective of the surgical procedure employed.
• The probability of achieving complete root coverage decreases dramatically as
the initial recession depth increases.

83. What periodontal recall interval is supported
by evidence?
• Recall sessions are an integral part of supportive periodontal therapy.
• convincing evidence regarding the appropriateness, risk‐benefit, and
cost‐effectiveness of different recall intervals is currently scarce.
• In patients affected by moderate to advanced periodontitis, a supportive
periodontal therapy protocol based on a 2‐4 month recall interval appears
reasonable. Limited data suggest that the amount/proportion of residual
diseased sites (intended as pockets or bleeding pockets) and risk assessment
tools may be of value in establishing the appropriate recall frequency.
Trombelli L, Simonelli A, Franceschetti G, Maietti E, Farina R. What periodontal recall interval is supported by evidence?.
Periodontology 2000. 2020 Oct;84:124-33.

84. Periodontal Ligament Stem Cells (Periodontal Progenitor)
: Current Status, Concerns, and Future Prospects
• The human clinical trial on stem cells based periodontal regeneration is promising.
The plethora of animal studies provide sound evidence to support the belief that
periodontal ligament stem cells (PDLSCs) can be used for periodontal
regeneration.
• Stem cell Application in Periodontal Regeneration Technique (SAI-PRT) using
direct PDLSCs has overcome the limitations and concerns of ex- vivo stem cell
culture methods like high cost, technique sensitivity, loss of stemness during cell
passage, genetic manipulation and tumorigenic potential. Clinical feasibility,
success and cost effectiveness over currently available techniques are
encouraging. The clinical utility of this novel idea is recommended.

85. EBA and Dental Implants:
• Most evidence is available for titanium implants, but some evidence exists to support the use of
hydroxy-apatite and titanium plasma-sprayed implant surfaces. (Taylor et al 2005).
• Also evidence exists to support the use of 2-stage systems which require a second stage surgery to
expose an implant, and also one stage implant systems.
• Clinicians should exercise caution when treating patients.
Who smoke
With untreated periodontal diseases
Poor oral hygiene
Uncontrolled systemic disease and
History of radiation therapy in the region or active skeletal
growth.

89. REVIEW OF CLINICAL POINTS
• Periodontists need tools to manage an ever-growing research database for
addressing clinical questions
• Using an Evidence-based Decision-Making approach allows you to incorporate
the most current and relevant scientific evidence into your clinical decision-
making
• Multiple sources are available to provide quality systematic reviews and meta-
analyses

90. • An evidence-based clinical practice clearly requires the data generated by clinical
research, and statistical analysis of the data provides a basis for the development of
treatment strategies and helps in the decision-making process.
• However, cost-benefit analyses and magnitude-of-change determinations of any
treatment approach depend on how much of the statistical differences can be
translated into clinically useable tools for daily practice.

91. Conclusion
• Evidence-based Periodontology is a tool to support decision-making and
integrating the best evidence available with clinical practice.
• The principles of evidence-based healthcare provide structure and guidance to
facilitate the highest levels of patient care.
• Evidence-based health care is not an easier approach to patient management
but should provide both the clinicians and the patients with greater confidence
and trust in their mutual relationship.

93. References
• Carranza’s Clinical Peroidontology 10th ed,11th edition.
• NeedlemanI, Moles DR ,Worthington H. Evidence-based periodontology, systematic reviews and research quality.
Periodontology 2000 2005; 37:12-28.
• Richards D. Not all evidence is created equal – so what is good evidence? Evid Based Dent 2003: 4: 17–18.
• Evidence-based approach. Dent Clin North Am 2002;46:54-62.
• Muir Gray JA. Evidence-based, locally owned, patient centred guideline development Br J Surg. 1997
Dec;84(12):1636-7.
• Vishal Anand et al .Evidence - Based Periodontology - A Review.Indian Journal of Dental Sciences.March 2013
Issue:1, Vol.:5
• Özkan Y, Orbak R (2016) The Evidence-Based Periodontology. JSM Dent 4: 1075.

94. • Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and
what it isn't. BMJ. 1996;312(7023):71‐72.
• Frantsve‐Hawley J, Kumar SS, Rindal DB, Weyant RJ. Implementation science and periodontal practice:
Translation of evidence into periodontology. Periodontology 2000. 2020 :188-201.
• Trombelli L, Simonelli A, Franceschetti G, Maietti E, Farina R. What periodontal recall interval is supported
by evidence?. Periodontology 2000. 2020 Oct;84:124-33.

95. THANK YOU