Dear Dr. Effie Ioannidou,
Congratulations on your appointment as Editor-in-Chief of the Journal of Periodontology. Your appointment gives you the opportunity to revolutionize the profession of periodontics. Periodontal therapy has not improved treatment outcomes in 30 years and it is directly related to what is published in the Journal of Periodontology. It is difficult to comprehend that the only improvement in periodontal treatment outcomes that has occurred in the last 50 years was the introduction of the barrier membrane, and this advancement was developed by industry, not by our profession. Just think if you had to go back 30 years for the treatment of a vast array of medical conditions that today are easily managed or often cured. We have completely failed the public we serve. There is a clear and obvious reason why periodontal therapy has not improved and it is due to the misinformation promoted in the Journal of Periodontology. The eradication of periodontal disease without the regeneration of lost tissue often fails either by reinfection or the development of root caries later in life. The only predictable long-term success for the treatment of periodontal disease is the regeneration of lost tissue. This is where the Journal of Periodontology has led us astray for going on 50 years and why we have made no improvement in treatment outcomes.
When cadaver bone grafts were introduced, they were accompanied by a long list of fanciful properties that have all been proven wrong by publications even in your own Journal. However, the profession has ignored the science and continued to promote these materials. Our professors, and consequentially our residents, have no training in bone biology or bone graft biology. Our residents come out of years of training with no understanding of what they are doing to their patients with the cadaver bone grafts they are required to use. Our profession has spent the last 30 years counting residual graft particles and measuring ridges without any effort to understand how these materials produce mineralization and what happens to this tissue long term. Because of the bias and misinformation published in the Journal, the vast majority of periodontists still think that these graft materials are resorbed and produce normal bone and they are all completely wrong with no science to support these misconceptions.
Cadaver tissues produce scar tissue called sclerotic bone which never remodels. If that is not bad enough, a recent article found that the soft tissue over these graft materials is ischemic and inflamed permanently. Our profession will never regenerate normal tissue with these materials and once cadaver bone grafts have been placed, the site is scarred forever and there is no way to ever regenerate normal tissue in the area of these materials. Anyone who uses the terms guided tissue regeneration or guided bone regeneration while using any cadaver graft material has no idea what they are talking about. Regeneration is the creation of normal tissue and cadaver bone grafts only produce scar tissue that never changes or remodels.
For our profession to heal periodontal lesions and improve treatment outcomes, we must use materials and methods that actually regenerate normal bone and gingiva. Only then can we continuously improve the material and the methods of application that will allow the innovation necessary to regenerate lost periodontal tissues and truly heal our patients.
If we are going to improve periodontal treatment outcomes for our patients, we must abandon cadaver bone grafts.
In order to correct the misinformation and move toward improving treatment outcomes for our patients, I offer the following recommendations:
First, reinstitute Letters to the Editor of the Journal of Periodontology.
Those that run the Journal have abolished letters to the editor because they want to have complete control of the narrative and no scientific debate. Any scientific journal that does not allow letters to the editor can keep the reader ignorant, resulting in the journal becoming nothing more than a cesspool of bias and misinformation.
Second, require that all statements about graft materials have legitimate research-based references or don’t allow the statements.
Many authors in the Journal of Periodontology make false statements without references because they cannot find any science to support their statements. Authors will also reference their statements with articles that do not support their statements knowing that peer review will never bother to read the references. If either of these situations occur, fire the peer reviewer. A case in point is a recent article in the Journal that was discussed in the following post:
Third, the Journal should have a bone biologist and a general pathologist to accurately assess the bone histology submitted to the journal.
Periodontists are not trained to evaluate bone histology. I am sure in the institution where you are employed you will have no problem finding these professionals who would gladly lend their services at a very reasonable fee. Also, congratulations on assuming the position of Chair of the Department of Orofacial Sciences at the University of California San Francisco (UCSF). In your pathology department is a very talented Oral Pathologist, Richard C. Jordan, DDS, PhD, FRCPath. He evaluated tissue samples of mineralized freeze-dried bone allograft and Bio-Oss for the following publication:
In this publication, he describes that both the allograft and Bio-Oss produced sclerotic bone. It is the type of bone that orthopedic surgeons spend their careers removing and replacing with metal joints. If you want to understand the clinical significance of sclerotic bone, you can review the following links:
The periodontology department is also under your direction. How easy it would be for the periodontal residents to take core samples of sockets grafted with cadaver bone grafts and have the samples evaluated by Dr. Jordan. If Dr. Jordan and I are correct, all of the cadaver bone samples will be sclerotic and it will end the discussion about what kind of bone is produced by these materials. This simple study would change the path of periodontics and move our profession from scarring our patients to healing our patients. If you want a positive control that stimulates bone growth and remodels into normal bone, SteinerBio would be happy to provide the materials and training in regenerative methodology.
Fourth, require that all papers involving histology submit extensive histology for review.
The histology must be low, medium, and high power images with enough images to allow a bone biologist and pathologist to accurately evaluate the tissue samples. Have the bone biologist and the pathologist select the appropriate images for publication, not the authors. Have the bone biologist and pathologist write a written report of what is presented. How wonderful it would be to have honesty and scientific excellence introduced into the Journal of Periodontology.
Fifth, request that the bone biologist and pathologist evaluate the staining and processing methods used for the histology presented.
Require the appropriate stains be used to accurately demonstrate the points being made in the publication. Require the authors use standard methods of processing and reject any processing methods that are outside normal process. An example of this type of abuse is presented in the following post:
Sixth, give priority to research papers that have authors with diverse backgrounds.
Many of the most important papers published in our field have diverse authors that have insight that does not exist in our profession alone. An example of this is a recent paper published by your Greek colleagues in Athens:
The authors of this paper had oral surgery, general surgery, pathology, biomaterials, and surgical research methodology experience, which resulted in a very well done and informative paper. If this exact research had been done by a group of periodontists, it would have been of little value because periodontists do not have the experience and depth of knowledge to accurately interpret the findings.
Seventh, require that peer review informs you of any statements they reject.
Rejecting truthful statements is just as harmful to science as allowing false statements.
Eighth, emphasize clinical research rather than esoteric laboratory research.
Periodontics is a clinical specialty. The Journal should be publishing clinical research that is aimed at improving treatment outcomes. The Journal should aim to be a Journal focused on regenerative medicine/dentistry. The Journal should have a place for innovative regenerative ideas. Universities have strict controls on any new procedure that can be performed on patients. Encourage clinicians in private practice to innovate. Many surgical procedures in medicine can have disastrous results when they fail—not so in periodontics. Any procedure that fails in periodontics can usually be easily corrected with no harm to the patients. Our young periodontists are trained to accept what the profession teaches them without question. A healthy profession teaches their students to question everything and encourages them to be the innovators.
If these suggestions are instituted, we will quickly learn the truth about how cadaver tissues are harming our patients and preventing progress.
To me, the failure to improve treatment outcomes is not just professional, it is also personal. When I sat in my first periodontology class in dental school, I knew that is what I wanted to do for the rest of my life. After dental school, I went directly to a graduate periodontal program and fell in love with the field. For the first five years of private practice, I eagerly looked to the profession to provide the innovation so I could continue to improve the treatment I provided my patients, but none arrived. After 10 years, I realized there would never be any improvement in the care I would provide my patients throughout my entire career. I could not spend my entire career saying the same things and doing the same tired mediocre treatment. I knew I had to quit the profession that I once loved. I quit and never intended to return to dentistry. After six years out of dentistry, a colleague became disabled and needed someone to keep his practice alive so he could sell it. I agreed and read all the literature published in the last six years and as I expected, there was nothing new. I decided to throw off the chains of the profession and create innovative therapy and materials that could improve treatment outcomes. I have spent the last 20 years studying bone, bone grafts, and regenerative medicine. I developed the use of the periosteum for periodontal regeneration, however, because this technique is regenerative and will not work with cadaver bone grafts, the procedure was rejected by the Journal of Periodontology and ultimately published in another journal:
I also realized that periodontics is controlled by the professors and lecturers that need to keep the current paradigm alive and they will work against any effort to bring change. As I knew periodontics was dead and would never allow for change, I abandoned trying to improve periodontal outcomes and focused on bone regeneration for dental implants to create the business I love.
Every dental school in the United States only teaches cadaver bone grafts. The professors in our universities only know how to use cadaver bone grafts and residents complete three years of training only being taught cadaver bone grafts. When cadaver bone grafts are exposed for the harm they are causing our patients in permanently scarred bone and failed implants, all these professors and lecturers will be obsolete. They will not allow the truth to take down their careers and reputations and they are actively publishing articles in the Journal of Periodontology to keep their false paradigm alive and keep the reader ignorant. A good example of this is a recent publication:
In my opinion, this article was designed, performed and published for only one reason: to protect the cadaver paradigm by trying to keep the profession ignorant of the fact that mineralized cadaver bone grafts have no positive biologic properties, are never fully resorbed, and never produce normal bone. Our assessment of this package of misinformation can be viewed through the following link:
To assist our path forward we at SteinerBio have condensed what we have learned into a two hour bone science video:
You have the opportunity to revolutionize the practice of periodontics by insisting that the Journal allow articles to be published that are critical of cadaver bone grafts and by scrutinizing articles published to promote the cadaver bone graft paradigm. The false cadaver bone graft paradigm is in the process of collapsing and you are in the position to seek the truth and usher in a new age of innovation. We cannot allow our young periodontists to face a career of never improving the care they provide. The future of periodontics is in your hands. Will your tenure as Editor-in-Chief at the Journal of Periodontology see no improvement in patient outcomes or will your tenure usher in a new and exciting time for our profession and the public we serve?
Dr. Greg Steiner
CEO, SteinerBio and OsNovum
Member, American Association of Bone and Mineral Research
Member, Tissue Engineering International and Regenerative Medicine Society
