2. prologueprologue
medicine is an “art of probabilities,”
at best, a “science of uncertainty”
uncertainty
Sir William Osler
1849-1919
„measurement has over promised
august 2015
Gene Glass
1940
and under delivered“
3. prologueprologue
mechanistic evidence
there is a physiological or (micro)biological
explanation how condition A may
pathomechanism
empirical evidence
evidence in patients that proofs there is a
dependance of condition B on condition A
gold standard: RCT
NCD evidence
lead to condition B
4. prologueprologue
primary outcome
surrogate outcomes
the most important outcome,
freedom from myocardial infarction and survival
a real clinical endpoint
measures of an effect that may correlate with
a real clinical endpoint, but not necessarily
cholesterol level
probing depth, BOP
tooth loss
endocarditis
bacteremia
outcome measures
6. prologueprologue
because of the multitude of individual
influences the same cause may
lead to very different effects
periodontitis is a risk factor
one cause one effect?
the clinical relevance is dependent on a
complex interplay from genetics to behavior
7. what we knowwhat we know
Disease periodontitis
as risk factor
association patho-
mechanism
Intervention:
surrogate
Intervention:
primary
Endocarditis ++ yes yes yes no
Recurrent
Pneumonia
++ yes yes n. a. yes
Cardiovascular
Disease
+ yes yes yes no
Chronic Kidney
disease
+ yes yes n. a. yes
Diabetes Mellitus + yes yes yes no
Cancer yes yes no no
COPD yes yes n. a. yes
Dementia yes yes no no
Gastritis yes yes n. a. yes
Rheumatoid
Arthritis
yes yes no no
periodontitis
8. what we knowwhat we know one example
cardiovascular disease
periopathogens in atherosclerotic vessel walls
Haraszthy et al. 2000, 2001, Mastragelopoulos
et al. 2002, Desvarieux et al. 2006
animal model: periopathogens
Offenbacher et al. 1999, Li et al. 2002
initiate atherosclerotic plaques
endothelial dysfunction reversed
Tonetti et al. 2007
by periodontal therapy
9. what we knowwhat we know
problems …
no large scale industrial or
pharmaceutical interests that lead
little interest of general medicine
to the funding of expensive studies
and politics in dental topics
dental science
10. what we knowwhat we know
we have found …, but the evidence is not
often because they …
feel insecure about their study
want new research-funding
sufficient. Further research is necessary.
classical expression of a scientist …
were obliged by peer reviewers
dental science
11. what we knowwhat we know
considering periodontitis, we want to
recommend preventive measures
what we need are relevant endpoints
because we want to convince …
the insurance-systems to spend
money on prevention
the patients to spend
their own money on prevention
underline our recommendations
in the field of general medicine to
What do we want?
the practitionerthe practitioner
12. what we know
in the mouth
clinical endpoints
what we know
we have observational evidence for
the practitioner
tooth loss
severe
periodontitis
inflammation
less …
13. what we knowwhat we know
The information and
concerning
60
70
80
90
1995 2000 2005 2010 2015
12 years
35-44-years
65-74 years
prevention-based
dental visits [%]
to talk to our patients
is more than enough
evidence we have today
the practitioner
general health?
14. what we knowwhat we know
Insurance-systems?
at least in Germany the highest levels
2 questions …
Will we ever reach these levels?
Do we really want insurance money?
of evidence are required
the practitioner
concerning
general health?
15. take hometake home
never hesitate to recommend
high-class preventive measures
we have all the hard endpoints in dentistry
and sufficient evidence in general medicine
relying on the money of our patients
people in the need of care
poor people
leaves at least 2 groups without prevention
(less developed countries)
