FOCUS: 25 years of the EFP: what has changed in European periodontology?
Clockwise, from top left: Phil Ower, Bahar Kuru, Mariano Sanz, Monique Danser, Peter Eickholz, France Lambert, Moshe Goldstein, Katrien Vermylen.
To mark the EFP’s 25th anniversary, Perio Insight asked the presidents of the national societies and the members of the EFP committees to talk about the changes over the last quarter century, about what the EFP has achieved, and about the federation’s priorities for the future.
The first of a series of three articles focuses on the question: “What have been the most important changes in European periodontology over the last 25 years?”
There are four areas in which periodontology in Europe has changed over the last 25 years, according to members of EFP committees and presidents of the national societies that make up the federation.
In terms of science, they highlight the advances in understanding the aetiology of periodontal diseases and the emergence of the links between periodontitis and systemic diseases such as diabetes.
Over the last quarter century, clinical practice has evolved thanks to the development of new treatments and an increased emphasis on prevention.
A third change concerns the development of implant dentistry and the rapid growth of patients with implants, together with the emergence of a new problem – peri-implantitis – and the challenges that this now poses to periodontal practitioners.
Finally, the EFP itself has played an important role in changing perio in Europe, bringing together the national societies, leading the way in scientific research, and organising the world’s most important conference on periodontology.
The reliance on science
“There has been a major shift in our understanding of perio aetiology over the last 25 years,” says Philip Ower (president, British Society of Periodontology).
He points out that, when he did his postgraduate perio training at the UCL Eastman Dental Institute in London in 1991, the emphasis was on bacterial causation, “which, of course, fuelled antibacterial therapies, both mechanical and chemical, including the widespread use of local antimicrobials.”
But things have changed and the emphasis has shifted towards the host response and the factors that influence it.
“Periodontal practice now is much more geared towards risk-factor control and the patient's role in disease causation. Treatment patterns have changed as a result,” says Dr Ower.
Iain Chapple (chairman, scientific affairs committee), highlights as an important change the recognition that “the major cause of tissue damage is the host’s response to a dysbiotic plaque biofilm.” This has led to a focus on host-risk determination and risk-factor management, and to “the recognition that thresholds of plaque accumulation required to trigger disease vary from one patient to the next – so preventive plans must be individualised.”
Bahar Kuru (president, Turkish Society of Periodontology) points to increased knowledge about periodontopathogens, host response, stress, and other risk factors and how these affect clinical features and disease susceptibility. “This has brought significant changes to the concept of aetiology, prevention, and treatment of periodontal diseases,” she says.
For Mariano Sanz (chairman, Workshop committee), the understanding of periodontal diseases has “clearly advanced, in line with developments in basic and experimental sciences.”
He highlights recent advances in genetic microbiology which are enabling the decoding of the human microbiome, including the oral microbiome.
Prof Sanz says that, thanks to the combination of this knowledge with recent advances in immunology and the understanding of inflammation, “our interpretation of the role of the bacteria and the host response in the aetiology and pathogenesis of gingivitis and periodontitis has clearly changed.”
Unlike 25 years ago, periodontitis is now widely considered to be “a complex chronic disease, where pathology results from the interaction between the bacteria accumulated on the tooth surfaces and the inflammatory and immune response from the host.”
This interaction is modulated by multiple risk factors, some with a genetic basis but others which depend on lifestyle. The latter have become the main focus of preventive strategies, says Sanz, who notes that “we have also recently understood that many of these behavioural risk factors – such as tobacco smoking, unhealthy nutritional habits, and poor oral hygiene – are shared by many of the most relevant chronic diseases, such as cardiovascular diseases and diabetes.”
In this context, he concludes, the “common risk factor” approach needs to be a key objective in the future role of dentists and other oral-health providers.
The perio link with systemic diseases
This growing awareness of the links between periodontitis and systemic diseases is also highlighted by the EFP’s new president Juan Blanco, who describes “increased knowledge of the pathogenesis of periodontal disease and its relation with systemic health and diseases” as one of the most significant developments of the last 25 years.
Ann-Marie Roos Jansåker (president, Swedish Society of Periodontology), highlights the increased scientific evidence of the “oral-systemic link”, while Monique Danser (president, Dutch Society of Periodontology) and David Herrera (Spanish Society of Periodontology and Osseointegration) also point to the association of periodontitis with systemic diseases and the implications of this link.
One of these implications is a greater emphasis on prevention. Prof Herrera highlights “the need to develop adequate preventive strategies, due to the high prevalence of periodontal diseases,” while Tiernan O’Brien (the new chairman of the external affairs committee) says that “the biggest change in 25 years is the public awareness of the importance of good oral hygiene and the role of preventive care in the maintenance of periodontal health.”
He says that patients “no longer find it acceptable that their teeth get loose, bleed and have to be removed” and that having healthy teeth and gums is now “something that people want and they are prepared to invest time, effort, and money in achieving this goal.” This was not the case 25 years ago, when dental practitioners faced “an uphill battle to convince patients that treatment of their condition was preferable to extractions.”
France Lambert (junior officer, postgraduate committee, and former president of the Belgian Society of Periodontology) hopes that the awareness of patients and health professionals “will keep rising at a growing pace” and points out that approaches to periodontal treatment have become less invasive and that there is now an increasing emphasis on prevention.
Also looking at things from the patient’s point of view, Iain Chapple comments that today there is a greater recognition that periodontitis is preventable and that treatment results from non-surgical approaches are very successful in motivated patients, which has reduced the need for surgical intervention.
In addition, adds Prof Chapple, “the recognition that periodontitis has a very significant impact on patient’s quality of life, self-esteem, and general well-being is driving a move towards recording patient outcomes as well as clinical outcomes.”
New treatments have made a difference
As has been noted, treatment for periodontal diseases has evolved considerably during the 25 years since the EFP was created.
“Advances in periodontal science and practice have radically changed treatment approaches”, says Prof Kuru, who highlights “the use of new hand and ultrasonic instrument designs, the use of magnification systems, lasers, and photodynamic, ozone, or probiotic treatments as adjunctives.”
She also mentions advances in surgical treatments and the importance of evidence-based data from randomised controlled trials, systematic reviews, and meta-analyses which help the periodontist decide what technique to use, when to use it, how to use it, and when not to use it.
“The use of new technology has influenced the therapeutic approach, both surgical and non-surgical,” says Joanna Kamma (external affairs committee, editor of Perio Insight). “Apart from new sonic and ultrasonic instruments, recent evidence demonstrates that laser light treatment has the potential to improve therapeutic outcomes and be a valuable adjunct to conventional treatments.”
“Periodontal therapy has become less surgical and surgical treatment has become more focused on a few particular defects that do not respond to nonsurgical treatment,” notes Peter Eickholz (president, German Society of Periodontology). “We have substantial evidence that even severely periodontally compromised teeth may be maintained over long periods if supportive treatment is provided.”
Mariano Sanz says that if the periodontist’s overall approach today is based on infection control, just as it was 25 years ago, “the specific approaches to prevention and treatment have evolved significantly.” He highlights “very effective antimicrobial compounds” that support daily oral hygiene practices and improved strategies for non-surgical periodontal treatment.
“Our ability to regenerate the destroyed periodontium has significantly improved and we have several technologies that have demonstrated a high success rate,” adds Sanz. “Similarly, in terms of soft-tissue reconstruction, we have improved surgical techniques and biomaterials that make the goal of reconstructing the gingival tissues around teeth achievable.”
Edwin Winkel (chairman, external affairs committee, 2010-16) highlights “the use of antibiotics, especially Metronidazole and/or in combination with Amoxicillin, on the basis of the microbiological profile of a patient”.
Dr Danser also notes how the use of antibiotics in the treatment of periodontitis has changed: “First they were used only for the acute situations and as prophylaxis, but nowadays they are also used for aggressive forms of periodontitis as well as in certain chronic forms.”
She also points to the importance of recognising the influence of lifestyle factors such as smoking, stress, diet, and oral hygiene on the onset and progression of periodontal diseases, and how these need to be included in treatment protocols.
As this suggests, communication with patients is crucial and this is also something that has evolved considerably over the last quarter century
“What I notice as the major difference is the way that we communicate with patients,” says Katrien Vermylen (president, Belgian Society of Periodontology).
“Patients become more involved in their treatment, they know more, and they have often looked up on the internet what periodontal treatment involves. We have a more informative approach towards patients and we help them in making the right decisions for their teeth and their health.”
Implants and peri-implantitis
One of the big changes over the last 25 years has been the growth of implant dentistry and the advent of a new problem – peri-implantitis.
“For me, the single biggest change has been related to the evolution of implant dentistry” says Dr O’Brien. “Initially, implants were seen as a revolutionary solution to the problem of tooth loss, and as periodontists we in Europe embraced this as a great new treatment strategy for our patients with advanced periodontal disease. No longer did we have to hold on to hopeless teeth but, rather, we could remove them and consider implant replacement.”
However, as time passed it became clear that “implants themselves also have issues that create problems in their own right” and it took a decade or more to recognise the problem of peri-implant infections. “Today we realise that the implant is not always a better option and we have come the full circle in recognising that holding onto teeth for as long as possible may still be the better option for many patients.”
O’Brien concludes that, while implants still have a huge role to play, “25 years on, we are better placed to decide when and where implants are indicated and how to use them more appropriately.”
This point is echoed by Iain Chapple who notes that recent systematic reviews have highlighted significantly better tooth survival rates and more cost-effective approaches to managing molars with furcations than placing new implants. This involves the recognition that “teeth are the best form of implant and implants are a replacement option for missing teeth and not teeth.”
He adds that emergence of peri-implant diseases as being far more prevalent than previously thought is a significant change and emphasises “the need to develop better protocols for implant case selection and managing peri-implant mucositis and peri-implantitis when it arises.”
Ann-Marie Roos Jansåker points out that periodontists have become “the outstanding clinicians and researchers” who have made a big impact on both the success of dental implants and on implant-related literature. This last point is echoed by Mariano Sanz who notes, “Most of the pivotal research in this area in the last two decades has come from the periodontal field.”
How the EFP has changed the perio picture
As well as the evolution of perio science, better understanding of periodontal diseases, new treatments, and the development of implant dentistry, the other big change from 25 years ago is the existence of the EFP itself.
For Moshe Goldstein (chairman, postgraduate committee), it is the formation of the EFP that has been the most important change over this period: “The EFP has built a pan-European platform for the profession, thus improving the periodontal science and clinical activity in all the member countries.”
This view is echoed by Anca Silvia Dumitriu (president, Romanian Society of Periodontology), who says that the advances in understanding periodontal diseases and in treatment were made possible by “creating and developing the European Federation of Periodontology, which played an essential role in spreading the professional information by organising congresses, courses, workshops, allowing each of its members to be up to date with the newest periodontal scientific achievements.”
A similar point is made by Shai Frankenthal, (president, Israeli Society of Periodontology and Osseointegration), who says that the most important change of the last quarter decade has been the creation of the EFP, which has become “the official and uniting body of European periodontology” along with the EuroPerio meetings, “which are a major development that needs to be recognized.”
Michèle Reners, who chairs the organising committee of the next meeting (EuroPerio9, Amsterdam, June 2018), highlights the EFP’s establishment of a “strong network” between the European perio societies. “More and more countries joined this federation and realised the possibilities they could achieve together,” she says.
“Strategic plans have been elaborated to improve the communication between societies but also external relations: contacts with policy makers, harmonisation of the perio education programme, and recognition of the speciality.”
The EFP’s initiative to convince the European Union to add periodontology to the list of dental specialities is considered by Jūratė Žekonienė (president, Lithuanian Association of Periodontology) to be “one of the most important changes in European periodontology.”
She says that “the periodontology speciality is recognised in Lithuania and we feel that our perio patients benefit from specialist care.”
Joanna Kamma adds that, from its very foundation, the EFP “has greatly contributed to the development of a communication strategy among national societies, disseminating evidence-based periodontal knowledge through EuroPerios, the Journal of Clinical Periodontology, the European Workshop in Periodontology, and the Master Clinic.”
Not all of today’s periodontists were practising 25 years ago. Ricardo Faria Almeida (president, Portuguese Society of Periodontology and Implantology) says he is too young to have a complete perspective of the last 25 years.
However, in his view, “European periodontology is every day more recognised as the real engine of periodontology around the world. This is a result of an intense work at a research and also at a clinical level. It is also a result of an intense work by the first European periodontologists.”
A lot has changed over the first 25 years of the EFP’s life. Much of this has been evolution rather than revolution, but it is clear that perio today is a very different position from when the EFP started out under the direction of European perio pioneers such as Klaus Lang and Jan Lindhe.
Summing it all up, Mariano Sanz says: “The changes in periodontology in these 25 years have not been dramatic, but they have significantly improved our understanding of periodontal diseases and the effectiveness of our preventive and therapeutic measures to provide periodontal health.”