[The significance and effect of guidelines 2. Observations concerning validation and recommendations with respect to guidelines]. / Betekenis en werking van richtlijnen 2. Opmerkingen over validering en aanbevelingen ten aanzien van richtlijnen.

The proper functioning of guidelines depends in part on correct validation. Validation requires an established norm. The professional and proto-pro-fessional paradigm uses different standards for validation based on different epistemological assumptions. Several different fundamental principles are also applied among healthcare professionals themselves. This leads to an insurmountable methodological difference whereby validation is not possible or meaningful at the moment. An important role seems reserved for the epistemology of the humanities to explain and interpret the guidelines. In addition, the operationalization of guidelines does not seem to be straightforward. The use of guidelines shows that unintended effects, such as the exclusion of patients from insurance and reimbursement, arise. In addition the number of guidelines is increasing to such an extent that implementation and enforcement are in danger of being compromised. Recommendations are made to monitor the significance and effect of guidelines.

[Significance and effect of guidelines 1. Some observations -concerning paradigms with respect to guidelines]. / Betekenis en werking van richtlijnen 1. Enkele opmerkingen over paradigma's ten aanzien van richtlijnen.

Clinical guidelines are currently receiving considerable attention. An important goals of guidelines are to improve the quality of care and to increase patient safety. Linguistic, legal and (proto)-professional paradigms differ on the meaning, scope and effectiveness of guidelines. The underlying propositions are very different. Since guidelines lack uniformity, the benefit of guidelines on the quality of care is unclear. In the use of the term guideline there is the implicit assumption that the significance and effect of a guideline remain unchanged in a changed context. In essence, this is an epistemological problem that to date has not been included in the debate. The consequence is that the effect of guidelines is changing from being a supporting instrument at the patient's level to becoming an enforceable standard in order to control the collective care process. In addition, it is questionable whether guidelines are the obvious choice to achieve greater quality and safety in healthcare. It is recommended to anchor the paradigmatic origin of guidelines within the law and the guidelines themselves.

Teeth with periodontal bone loss, cigarette smoking and plasma cotinine levels.

The aim of the present study is to assess teeth with periodontal bone loss, cigarette smoking and plasma cotinine levels. We enrolled 120 untreated periodontal patients with chronic periodontitis into the study. The group comprised 48 men and 72 women, ranging in age from 21 to 75 years (mean age, 42.4 years). We divided the patients into five groups based on self-reported smoking status: (1) heavy smokers (n=35); (2) light smokers (n = 17); (3) recent former smokers (n = 8); (4) long-term former smokers (n = 17); (5) non-smokers (n = 43). We calculated packyear: (number of cigarette/day/20 x years) for all smokers. Smoking status was confirmed by measurement of plasma cotinine levels in 116 subjects. Periodontal disease was assessed on a full set of periapical radiographs. The number of teeth with bone loss was scored in four categories (no bone loss, light bone loss, moderate bone loss or serious bone loss) in all patients. The results demonstrated that plasma cotinine levels correlated significantly with the number of cigarettes smoked per day. Moreover, heavy smokers had fewer teeth with no bone loss (P < 0.001) and more teeth with moderate bone loss (P < 0.001) than non-smokers. In addition, we found a negative correlation between packyears and the number of teeth with no bone loss (P < 0.04) and a positive correlation between packyears and the number of teeth with light bone loss (P < 0.005). However, we found no correlation between plasma cotinine levels and the number of teeth with bone loss. These clinical findings suggest that cigarette smoking affects the number of teeth with or without periodontal bone loss, and this effect is related to the degree of smoking exposure.

Elevation of systemic markers related to cardiovascular diseases in the peripheral blood of periodontitis patients.

BACKGROUND: Periodontitis is a common, often undiagnosed, chronic infection of the supporting tissues of the teeth, epidemiologically associated with cardiovascular diseases. Since C-reactive protein (CRP) and other systemic markers of inflammation have been identified as risk factors for cardiovascular diseases, we investigated whether these factors were elevated in periodontitis. METHODS: Consecutive adult patients with periodontitis (localized n = 53; generalized n = 54), and healthy controls (n = 43), all without any other medical disorder, were recruited and peripheral blood samples were taken. RESULTS: Patients with generalized periodontitis and localized periodontitis had higher median CRP levels than controls (1.45 and 1.30 versus 0.90 mg/L, respectively, P = 0.030); 52% of generalized periodontitis patients and 36% of the localized periodontitis patients were sero-positive for interleukin-6 (IL-6), compared to 26% of controls (P= 0.008). Plasma IL-6 levels were higher in periodontitis patients than in controls (P = 0.015). Leukocytes were also elevated in generalized periodontitis (7.0 x 10(9)/L) compared to localized periodontitis and controls (6.0 and 5.8 x 10(9)/L, respectively, P= 0.002); this finding was primarily explained by higher numbers of neutrophils in periodontitis (P= 0.001). IL-6 and CRP correlated with each other, and both CRP and IL-6 levels correlated with neutrophils. The current findings for periodontitis were controlled for other known factors associated with cardiovascular diseases, including age, education, body mass index, smoking, hypertension, cholesterol, and sero-positivity for CMV, Chlamydia pneumoniae, and Helicobacter pylori. CONCLUSIONS: Periodontitis results in higher systemic levels of CRP, IL-6, and neutrophils. These elevated inflammatory factors may increase inflammatory activity in atherosclerotic lesions, potentially increasing the risk for cardiac or cerebrovascular events.

Peptostreptococcus micros smooth and rough genotypes in periodontitis and gingivitis.

BACKGROUND: Two genotypes can be distinguished within the species Peptostreptococcus micros: a smooth (Sm) and a rough (Rg) type. To date no systematic study has been performed on the prevalence and proportion of both types in untreated periodontitis patients and subjects without destructive periodontal disease. Therefore, the present study was performed to investigate: 1) the relative importance of the Sm and the Rg genotype of P micros in periodontitis and gingivitis; 2) the correlation between smoking and the 2 genotypes of P micros; and 3) the systemic antibody response against the 2 genotypes in relation to the periodontal condition and smoking. METHODS: A total of 104 untreated periodontitis patients and 41 individuals with gingivitis underwent clinical examination and microbiological sampling. Pocket samples were cultured anaerobically on blood agar plates to determine the prevalence and proportion of the Sm and Rg types of P micros. Serum antibody titers against both types of P micros were determined in all subjects by enzyme-linked immunosorbent assay (ELISA) using whole bacterial cells as antigen. Additionally, in a representative group of subjects, the antigen specificity of the serum antibodies was assessed by immunoblotting experiments. RESULTS: The prevalence of the Sm genotype was higher in subjects with periodontitis (94%) compared to subjects with gingivitis (59%), whereas the prevalence of the Rg type was not significantly different (38% versus 29%). Similar analyses were performed for subgroups of smokers and non-smokers; within the periodontitis group, the prevalence of the Sm type was not different between smokers and non-smokers (96% and 92%, respectively), whereas the prevalence of the Rg type was higher in smokers (48%) compared to non-smokers (19%). No difference in prevalence of both types was observed between smokers and non-smokers within the gingivitis group. The titers and specificity of P micros-specific immunoglobulins in periodontitis patients were not different from those in gingivitis subjects, nor were they related to smoking status or culture-positivity. CONCLUSIONS: The results of this study suggest that both the Sm and the Rg genotypes of P micros are part of the normal oral microbiota. However, the elevated prevalence of the Sm genotype in periodontitis and the elevated prevalence of the Rg type in periodontitis patients who smoke implies that both types can behave as opportunistic pathogens in destructive periodontal disease.

[Insurability of periodontal care in 1999]. / Verzekerbaarheid van parodontale zorg in 1999.

In this study an overview of dental insurance in the Netherlands for periodontal care is presented. Since the dental insurance reform in 1995, dental care is no longer part of the collective health care system. Patients are therefore obliged to enter the market for private dental insurance. Of the 118 available insurance packages 86 (73%) contain dental care. Sixty eight of these packages (58%) include periodontal care. A minority of the companies (4) include periodontal care in all packages. Fifty two percent of the companies apply additional terms, which reduces the scope of the claims. In this paper it is concluded that a sufficient amount and diversity of insurance packages is present. Since patients may not know about the diversity, insufficient coverage of treatment costs may result. It is concluded that market elements are successful integrated in the field of dental insurance. It has to be shown in the future if this success will lead to an increase of dental and periodontal health of the patients.