Journal of Indian Society of Periodontology
Journal of Indian Society of Periodontology
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Year : 2019  |  Volume : 23  |  Issue : 1  |  Page : 1-2  

Surrogate endpoints… Uncommon for a common man!

Editor, Journal of Indian Society of Periodontology, Professor, Department of Periodontology, Institute of Dental Studies and Technologies, Kadrabad, Modinagar, Ghaziabad - 201 201, Uttar Pradesh, India

Date of Web Publication3-Jan-2019

Correspondence Address:
Ashish Kumar
Editor, Journal of Indian Society of Periodontology, Professor, Department of Periodontology, Institute of Dental Studies and Technologies, Kadrabad, Modinagar, Ghaziabad - 201 201, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jisp.jisp_671_18

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How to cite this article:
Kumar A. Surrogate endpoints… Uncommon for a common man!. J Indian Soc Periodontol 2019;23:1-2

How to cite this URL:
Kumar A. Surrogate endpoints… Uncommon for a common man!. J Indian Soc Periodontol [serial online] 2019 [cited 2022 Aug 13];23:1-2. Available from:

Historically periodontal therapy has never been on the priority list of any patient. The reasons could be many…. Lack of knowledge, pain, chronicity of the disease, disease occurrence in older age group, when treatment preferences are for other systemic diseases, economics could be few of them. Other factors which play a role in non-prioritizing periodontal treatment could be myths (may be because of lack of knowledge), hearsay (with quite a bit of reality) about post-treatment effects of sensitivity, increase in mobility, recession, spacing becoming visible and ultimately unaesthetic appearance.

Another major factor which plays a role in patient not giving adequate importance to periodontal therapy requirements is the inability of periodontist to demonstrate in most of the conditions what they have achieved after treatment. For example, in endodontics, patients get relieved of pain after the therapy or gets a new crown which gives him an esthetic look and functional tooth that is so motivating for him to get the treatment. Similarly, in orthodontics, a beautiful smile even after a difficult, costly prolonged treatment of more than one year, is the incentive for which the patient is motivated to take the treatment.

We have nothing much to show as post-operative outcomes in most of the procedures except for few esthetic surgeries. Rather the patients have lot of complaints in this period. And the irony is that the procedures in which we can show results are barely asked for, by patients in Indian clinical practice scenario. The worrying aspect of these esthetic procedures are their unpredictable results. We deal with periodontal diseases in surrogate endpoints like pocket depth, clinical attachment loss, furcation involvement etc., rather than using true endpoints.

We diagnose the periodontal diseases with parameters which are surrogate, we evaluate our treatment success with same surrogate endpoints and in long term we use the same surrogate parameters to determine whether the patient has maintained the oral hygiene or not. The worst part is that we use the same surrogate endpoints even to explain to the patients what has happened at the time of diagnosis, what we plan to do and what can be expected after treatment.

What does patient understand by pocket depth or clinical attachment loss (CAL) or furcation involvement or gingival colour changes at the time of diagnosis. We try to tell them about bone loss which they cannot understand as it is not visible and they are at their imaginative best. How much a radiograph can explain the amount of bone loss to a layman is still a question unanswered. Even after the therapy is over, we evaluate the above mentioned parameters and are very elated if they have improved.

My question is, how does it matter to the patient if pocket depth is reduced or there is a CAL gain or bone gain or improvement in furcation status?

How many patients have we encountered in our practice/departments who have primarily come for the treatment of increased pocket depth or loss of attachment or furcation involvement and want them to be treated. The answer would be none till date.

Patients come with complaint of dirty teeth, bleeding, mobility, recession, halitosis, spacing, inability to masticate and want these to be treated and eventually want to save the tooth. The most important question that is asked by a periodontal patient is “how long will these teeth last if I take the treatment”. Ultimately they want all these to be treated because they want the teeth to survive functionally and esthetically for a long time.

So, the fundamental aim of periodontal therapy is to save teeth for the patient to use it essentially for longest period of time.

I would put across a hypothetical situation; how we, while using surrogate parameters, tend to forget the actual goals we should look at. An example of case of treated periodontitis where periodontally excellent results have been obtained. There is normal pocket depth, no bleeding on probing or any other signs of periodontal disease on reduced periodontium. The reduced periodontium has resulted in post-operative recession, which is a common after-effect of periodontal surgeries. After some time, the exposed root surface encounters root caries and pulp involvement. The tooth had to extracted. The reason may seem to be caries but why did caries occur…. because of exposed root surface. Did the patient get periodontal treatment for reduction of pocket, recession, CAL gain or to lose the teeth because of caries? The real question is “Did we succeed in achieving our ultimate goal of periodontal therapy”? The answer is a big No. We might have treated periodontal disease effectively in this case, got our surrogate parameters in right proportions post-treatment but loss of tooth (even because of caries) has resulted in overall failure as long term survival of tooth was not possible. The patient was ultimately not benefited from the treatment as loss of tooth resulted in loss of function and esthetics.

There is no doubt that the surrogate parameters have been proved with lot of studies that they indirectly infer about the long term survival of teeth but in a practical sense they are of no use to the patient.

Patients will understand the importance of periodontal therapy if we could explain in quantitative terms how much bleeding has reduced, how much is the improvement in mobility, improvement in halitosis, recession, spacing etc., And ultimately how long the patient, who has undergone periodontal therapy, can effectively use the teeth for function.

Till we do not explain the patient our treatment modalities in the terms the patient can understand (patient centric outcomes) and can approximately tell the patient how long is he going to benefit with the therapy (the life span of the tooth) till then it will always be a very hard task to motivate the patient to undertake treatment for periodontitis.

We should look at using patient centric outcomes to diagnose, evaluate and explain to the patient his periodontal condition for him to be motivated and remain interested in periodontal therapy. The use of patient centric outcomes provides patient centric tangible benefits and not clinician centric results. The periodontal therapy becomes more meaningful and of relevance to the patient.

At this moment, we may not know how to effectively use these patient centric parameters for tangible patient benefits, but we will never have an answer to this question till we start working on it and try to find answers. We need to get over with our fascination with surrogate parameters.

As someone rightly said “Problems are mere absence of ideas.”


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