Algorithms in Periodontology

The other day I was talking with someone about the use of algorithms to guide clinical decisions, and the conversation revived the interest in me for use of flow diagrams to make explicit the decision-taking processes involved in what we have called for years “clinical judgment”.

Including the complexities of clinical situations in a flow diagram is a challenge that many may consider above the possibilities of algorithms. At the end, clinic method is individual, and the real utility of a periodontal algorithm, as I see it, would mainly be to make it applicable in more than one situation. However, one must immediately recognize that building an algorithm including all the possibilities is both cumbersome and useless, because the diagram would be so complicated that it would be extremely hard to use.

So, is it futile to look for generalizations when it comes to clinical situations? I don’t think it is, if we recognize the limitations of the method and don’t make a prescription of it. Modern clinical science is built (better yet, should be built) upon looking for general patterns in ‘cases’, finding differences and disjunctives, and applying general principles to clinical situations. It should be a combination of the analytic and the synthetic methods. In the clinical world, this process often starts with observation, and through the scientific method, it is systematized looking for certain level of generalization that covers as many patients as possible, while keeping space for the intrinsic individualities of the clinical method. On occasions, it is the application of a principle to an individual situation what makes the case a success. Have you ever seen Dr. House in his TV show? There is an example of what I am talking about.

I propose an interesting clinical exercise for any clinician: Creating a diagram following what is (or was) involved in the periodontal treatment for Mrs. Jones. Then, doing it for Mr. Smith, and Ms. Wong, and many other patients, including, at least for some of them, as many variables as possible; why did we go with a graft in this case and not in the other? Why do we prescribe this exam, or that antibiotic? When do we consider the extraction instead of a more conservative approach? What options do we consider for a, b, or m situation?

Thinking about these things, I remembered flipping the pages of a Perio book in the Library of the School of Dentistry of Universidad de Antioquia. It presented algorithms for many common clinical periodontal situations. I only remember the drawings, not the author or the title (shame on me). I also remembered an amazing conversation about the potential and limitations of this approach informally with Alejandro Botero, maestro y señor -un saludo. But I didn’t remember the details (shame on me… twice!). Anyway, I went to the oracle (A.KA. Google) and searched for strings like periodontal algorithm, periodontology algorithm, clinical algorithm, and others. Results: many interesting links, including the book I checked years ago: Critical Decisions in Periodontology. I just found it, and I don’t know if this is the most recen edition, or anything.  I’ll find out later.