Analia Veitz-Keenan

The impact of smoking on failure rates, postoperative infection and marginal bone loss of dental implants.

Data sourcesElectronic searches were undertaken in PubMed/Medline, Web of Science, Cochrane Oral Health Group Trials Register as well as hand searching.Study selectionClinical human studies, either randomised or not, providing outcome data for dental implant failure in smokers and non-smokers in any group of patients with no follow-up restrictions. Patients smoking a minimum of one cigarette a day were classified as smokers and implant failure was considered as the complete loss of the implant.Data extraction and synthesisThree authors independently participated in the inclusion criteria and disagreements were resolved by discussion. Quality assessment of the studies was performed using a scale to appraise observational studies. From the selected studies, data were extracted when available which included year of publication, study design, country, setting, number of patients, type of smokers, age, follow-up, days of antibiotic prophylaxis, failure, postoperative infection, marginal bone loss, implant surface, dental arch receiving implants, type of prosthetic rehabilitation and opposing dentition. For the meta-analysis, implant failure and postoperative infection were evaluated as dichotomous outcomes, while weighted mean differences were used for marginal bone loss as a continuous outcome. The statistical unit was the implant. Heterogeneity was calculated using I2 test.ResultsFrom 1432 records identified, 107 publications were included in the review for the qualitative and quantitative synthesis. One hundred and four studies compared implant failure rates. From the total studies, the authors judged 85 to be of high quality and 22 of moderate quality. The meta-analysis for failure rate resulted in a statistically significant overall result of risk ratio (RR) of 2.23 (95% CI 1.96-2.53) heterogeneity of I2: 51%. The meta-analysis of four studies evaluating the risk of postoperative infections in smokers presented a statistically significant result with an RR: 2.01, 95% CI 1.09-3.72, heterogeneity I2: 0%, and the marginal bone loss had an overall statistically significant difference of MD 0.32, 95% CI 0,21-043; heterogeneity in this case was I2: 95%.ConclusionsThe insertion of implants in smokers affected the failure rates, the risk of postoperative infections, as well as the marginal bone loss. The results should be interpreted with caution due to the presence of uncontrolled confounding factors in the included studies.

Marginal bone loss and dental implant failure may be increased in smokers.

Data sourcesAn electronic search was performed in PubMed, Web of Science and the Cochrane Central Register of Controlled Trials up to February 2015. References of included studies were also searched. No language restrictions were appliedStudy selectionProspective, retrospective and randomised clinical trials that compared marginal bone loss and failure rates between smokers and non-smokers. Implant failure was considered as total loss of the implant. Studies with patients who had periodontal disease prior to treatment or who had metabolic diseases were excluded.Data extraction and synthesisTwo reviewers were involved in the research and screening process and disagreements were resolved by discussion. The quality of the studies was analysed using the Newcastle-Ottawa scale for non-randomised clinical trials. Data extracted from the studies included, when available: follow up period, number of subjects, smoking status, number of implants placed, implant system, implant length and diameter, healing period, antibiotics and mouth-rinse use, marginal bone loss, failure rate and drop-outs. For binary outcomes (implant failure) the estimate of the intervention effect was expressed in the form of an odds ratio (OR) with the confidence interval (CI) of 95%. For continuous outcomes (marginal bone loss) the average and standard deviation (SD) were used to calculate the standardised mean difference with a 95% CI. Meta-analysis was performed for studies with similar outcomes, I2 a statistical test was used to express the heterogeneity among the studies. Publication bias was explored as well.ResultsA total of 15 observational studies were included in the review. The number of participants ranged from 60 to 1727 and the average age was 52.5 years. The follow-up period ranged from eight to 240 months. The total number of implants placed was 5840 in smokers and 14,683 in non-smokers. The Branemak system, (Noble Biocare AB, Goteborg, Sweden), was the most commonly used implant system. There was a statistically significant difference in marginal bone loss favouring the non-smoking group (SMD 0.49, 95% CI 0.07-0.90). There was an increase in marginal bone loss in the maxillae of smokers compared to the mandible (SMD 0.40, 95% CI 0.24-0.55) and a statically significant difference in implant failure in favour of the non-smoking group OR 1.96, 95% CI 1.68-2.30.ConclusionsThe risk of marginal bone loss and implant failure is increased in smokers compared to non-smokers, however, the results should be interpreted with caution since the data from the review are provided by retrospective and cohort studies.

Cannabis use and oral diseases

Data sourcesMedline and the Cochrane Central register of controlled trails (CENTRAL).Study selectionRandomised Controlled Trials, Controlled Clinical Trials and Cohort Studies conducted on humans investigating cannabis usage were included. Screening was performed independently by two reviewers. Only English language studies were included. Case reports, letters and historical reviews were excluded.Data extraction and synthesisA narrative synthesis was conducted.ResultsSeven studies were included and a range of cannabis-associated oral side effects identified.ConclusionsBased on the limited data, it seems justified to conclude that with increasing prevalence of cannabis use, oral health care providers should be aware of cannabis-associated oral side effects such as xerostomia, leukoedema and an increased prevalence and density of Candida albicans.

Insufficient evidence for sinus lifts over short implants for dental implant rehabilitation

Data sourcesThe Cochrane Oral Health Groups Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL), Medline and Embase databases were searched with no language or date restrictions.Study selectionTwo reviewers independently selected studies. Randomised controlled trials (RCTs) of different techniques and materials for augmenting the maxillary sinus for rehabilitation with dental implants that reported the outcome of implant success or failure at least four months after initial loading were considered.Data extraction and synthesisData were extracted independently by two reviewers and study risk of bias assessed. Results were expressed using fixed-effect models as there were either fewer than four studies or we used Peto odds ratios (ORs) for dichotomous data when there were zero cells in either the treatment or control or both arms and the number of trials was small.ResultsEighteen trials involving 650 patients were included. Five studies were considered to be at low risk of bias, 11 at high risk and two of unclear risk. Four trials (102 patients) evaluated short implants (5 to 8.5 mm long) as an alternative to sinus lift in bone with residual height between 4 and 9 mm. One year after loading there was insufficient evidence to claim differences between the two procedures for prosthesis failure (OR (Peto) 0.37, 95% confidence interval (CI) 0.05 to 2.68; three trials) or implant failure (OR (Peto) 0.44, 95% CI 0.10 to 1.99; four trials). There was however an increase in complications at treated sites when undertaking the sinus lift (OR (Peto) 4.77, 95% CI 1.79 to 12.71, P value = 0.002; four trials).Fourteen trials (548 patients) compared different sinus lift techniques. Only three comparisons included more than one trial. These were bone graft versus no bone graft, autogenous bone versus bone substitute, bone graft with or without platelet-rich plasma (PRP). There was insufficient evidence to claim a benefit for any of these techniques for the primary outcomes of prosthesis and implant failure.The other comparisons with single studies were rotary versus piezosurgery to open a lateral sinus window, two different bone substitutes, use or not of a membrane to seal the lateral window, one- versus two-stage lateral sinus lift, two-stage granular bone versus one-stage autogenous bone blocks and crestal versus lateral sinus lift; two trials compared three different crestal sinus lifting techniques: rotatory versus hand malleting (patients preferred rotatory instruments over hand malleting) and hand versus electric malleting. There was no evidence of a benefit for any sinus lift procedure compared to any other for the primary outcomes prosthesis or implant failure.ConclusionsThere is moderate quality evidence which is insufficient to determine whether sinus lift procedures in bone with residual height between 4 and 9 mm are more or less successful than placing short implants (5 to 8.5 mm) in reducing prosthesis or implant failure up to one year after loading. However, there are more complications at sites treated with sinus lift procedures. Many trials compared different sinus lift procedures and none of these indicated that one procedure reduced prosthetic or implant failures when compared to the other. Based on low quality evidence, patients may prefer rotary instruments over hand malleting for crestal sinus lift.

Antibiotic use at dental implant placement

Data sourcesCochrane Oral Health Groups Trial Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE via OVID and EMBASE via OVID. Databases were searched with no language or date restrictions.Study selectionTwo authors independently reviewed the titles and the abstracts for inclusion. Disagreements were resolved by discussion. If needed, a third author was consulted. Included were randomised clinical trials with a follow-up of at least three months which evaluated the use of prophylactic antibiotic compared to no antibiotic or a placebo and examined different antibiotics of different doses and durations in patients undergoing dental implant placement. The outcomes were implant failure (considered as implant mobility, removal of implant due to bone loss or infection) and prosthesis failure (prosthesis could not be placed).Data extraction and synthesisStandard Cochrane methodology procedures were followed. Risk of bias was completed independently and in duplicate by two review authors. Results were expressed as risk ratios (RRs) using a random-effects model for dichotomous outcomes with 95% confidence intervals (CI). The statistical unit was the participant and not the prosthesis or implant. Heterogeneity including both clinical and methodological factors was investigated.ResultsSix randomised clinical trials with 1162 participants were identified for the review. Three trials compared 2 g of preoperative amoxicillin versus placebo (927 participants). One trial compared 3 g of preoperative amoxicillin versus placebo (55 participants). Another trial compared 1 g of preoperative amoxicillin plus 500 mg four times a day for two days versus no antibiotic (80 participants). An additional trial compared four groups: (1) 2 g of preoperative amoxicillin; (2) 2 g of preoperative amoxicillin plus 1 g twice a day for seven days; (3) 1 g of postoperative amoxicillin twice a day for seven days and (4) no antibiotics (100 participants). The overall body of the evidence was considered moderate.The meta-analysis of the six trials showed a statistically significant higher number of implant failures in the group not receiving antibiotics, RR= 0.33 (95% CI; 0.16 to 0.67) P = 0.0002.The number needed to treat for one additional benefit outcome (NNTB) to prevent one person having an implant failure is 25 (95% CI; 14 to 100) based on an implant failure of 6% in participants not receiving antibiotics.There was borderline statistical significance for prosthesis failures (RR= 0.44 (95%CI; 0.19 to 1.00) with no statistically significant differences for infections or adverse events. No conclusive information for the different durations of antibiotics could be determinedConclusionsThere is statistically significant evidence suggesting that a single dose of 2 g or 3 g of amoxicillin given orally is beneficial in reducing dental implant failure in ordinary conditions. No significant adverse events were reported. It is still unknown whether post-operative antibiotics are beneficial and which antibiotic is more effective.

Systemic nucleoside antiviral agents may be effective in prevention of recurrent herpes labialis

Data sourcesThe Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Medline and Embase databases were searched together with the reference lists of primary studies, commentaries and reviews. Grey literature resources including the System for Information on Grey Literature in Europe, the Scopus Web and Patent searches, Proquest Dissertations and Theses Fulltext, the Index to Scientific and Technical Proceedings and the clinical trials registry (http://clinicaltrials.gov) were also searched.Study selectionRandomised controlled trials (RCTs) involving nucleoside antiviral agents for the prevention of recurrent oral herpes in healthy immunocompetent subjects ≥12 years old were included. No language restrictions were applied. Study quality was assessed following Cochrane guidelines.Data extraction and synthesisData were abstracted using a standardised data extraction form and analysed with meta-analysis carried out only with studies that reported the same outcome measure.ResultsTen studies were included, only one study was considered to have a low risk of bias, five an unclear risk and four a high risk of bias. Oral acyclovir (800-1,600 mg daily) and valacyclovir (500 mg daily for four months) were shown to be effective in the prevention of RHL when taken prior to the appearance of any symptoms or exposure to triggers.ConclusionsThis review found support for the use of systemic acyclovir and valacyclovir for the prevention of RHL. However, the findings from this review should be interpreted with caution, because the methodologic assessment of the quality of the included studies showed an unclear risk of bias in five out of the ten included papers, and a high risk of bias in four studies.

Implant outcomes poorer in patients with history of periodontal disease

Data sourcesMedline and Embase databases and bibliographies of all included articles and relevant review articles were screened for possible inclusion.Study selectionLongitudinal studies were included reporting on implant survival, success, incidence of peri-implantitis, bone loss and periodontal status and on partially dentate patients with a history of treatment for periodontitis. There were no language restrictions for the included studies.Data extraction and synthesisAuthors independently and in duplicate assessed the studies for eligibility and data extraction. Disagreements were resolved by discussion and consensus. The methodological quality assessment of the included studies was done using an adapted Newcastle-Ottawa Scale (NOS). Confounding factors such as smoking, systemic disease influencing osseointegration, chemotherapy and radiation were assessed and adjusted in the analysis. Data were organised into tables and grouped in accordance with the study design.ResultsTwenty-four studies reported in 27 publications were included. Implant survival and success rate were higher in periodontally healthy patients.Twelve prospective cohort studies, five case series with a control group, four retrospective cohort studies and three studies with a sub group comparison were included.Bone loss and peri-implantitis were increased in patients with a history of treated periodontitis. More complications were reported in patients presenting with more severe forms of periodontitis. High heterogeneity among the studies in terms of study design, population, therapy, unit of analysis, inconsistent definitions of baseline and outcomes, inadequate reporting and confounding factors meant a meta-analysis could not be performed.Most of the studies showed better implant survival rates for the non-periodontitis group ranging from 91.67% to 100% compared to the treated periodontitis group 79.22% to 100% over a 1.2 to 16 year follow-up.ConclusionsImplants placed in patients treated for periodontal disease are associated with higher incidence of biological complications and lower success and survival rates than those placed in periodontally healthy patients. Severe forms of periodontal disease are associated with higher rates of implant loss. The conclusion of the review is limited by the strength of the evidence.

Trials needed to identify best management of iatrogenic inferior alveolar and lingual nerve injuries

Data sourcesThe Cochrane Oral Health Groups Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL), Medline and Embase databases were searched with no language or date restrictions.Study selectionThree reviewers independently selected studies. Randomised controlled trials (RCTs) involving interventions to treat patients with neurosensory defect of the inferior alveolar or lingual nerve or both as a sequela of iatrogenic injury were considered.Data extraction and synthesisStandard Cochrane methodological procedures were followed.ResultsTwo studies considered at high risk of bias, reporting data from 26 analysed patients were included. Both studies investigated the effectiveness of low-level laser treatment compared to placebo laser therapy on inferior alveolar sensory deficit as a result of iatrogenic injury. Two studies assessed as at high risk of bias, reporting data from 26 analysed participants were included in this review. The age range of participants was from 17 to 55 years. Both trials investigated the effectiveness of low-level laser treatment compared to placebo laser therapy on inferior alveolar sensory deficit as a result of iatrogenic injury.Patient-reported altered sensation was partially reported in one study and fully reported in another. Following treatment with laser therapy, there was some evidence of an improvement in the subjective assessment of neurosensory deficit in the lip and chin areas compared to placebo, though the estimates were imprecise: a difference in mean change in neurosensory deficit of the chin of 8.40 cm (95% confidence interval (CI) 3.67 to 13.13) and a difference in mean change in neurosensory deficit of the lip of 21.79 cm (95% CI 5.29 to 38.29). The overall quality of the evidence for this outcome was very low. No studies reported on the effects of the intervention on the remaining primary outcomes of pain, difficulty eating, speaking or taste. No studies reported on quality of life or adverse events.ConclusionsThere is clearly a need for randomised controlled clinical trials to investigate the effectiveness of surgical, medical and psychological interventions for iatrogenic inferior alveolar and lingual nerve injuries. Primary outcomes of this research should include: patient-focused morbidity measures including altered sensation and pain, pain, quantitative sensory testing and the effects of delayed treatment.

Ibuprofen is superior to paracetamol for pain relief following third molar removal

Data sourcesThe Cochrane Oral Health Groups Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), Medline, Embase and the metaRegister of Controlled Trials were searched with no language restrictions.Study selectionRandomised controlled double-blinded clinical trials using the third molar model were included.Data extraction and synthesisTwo review authors independently and in duplicate extracted data. The proportion of patients with at least 50% pain relief (based on total pain relief (TOTPAR) and summed pain intensity difference (SPID) data) was calculated for all three drugs at both two and six hours post-dosing and meta-analysed for comparison.ResultsSeven studies involving 2241 patients were included. Two studies were considered to be at low risk of bias, three at high risk and two unclear risk of bias. Ibuprofen was found to be a superior analgesic to paracetamol at several doses, with high quality evidence suggesting that ibuprofen 400 mg is superior to 1000 mg paracetamol based on pain relief (estimated from TOTPAR data) and the use of rescue medication meta-analyses. Risk ratio (RR) for at least 50% pain relief (based on TOTPAR) at six hours was 1.47 (95% confidence interval (CI) 1.28 to 1.69; five trials) favouring 400 mg ibuprofen over 1000 mg paracetamol, RR for not using rescue medication (also favouring ibuprofen) was 1.50 (95% CI 1.25 to 1.79; four trials). For combined drug RR for at least 50% of the maximum pain relief over six hours of 1.77 (95% CI 1.32 to 2.39) (paracetamol 1000 mg and ibuprofen 400 mg) (one trial; moderate quality evidence). RR not using rescue medication 1.60 (95% CI 1.36 to 1.88) (two trials; moderate quality evidence). Adverse events were comparable between the treatment groups, but no formal analysis could be undertaken.ConclusionsThere is high quality evidence that ibuprofen is superior to paracetamol at doses of 200 mg to 512 mg and 600 mg to 1000 mg respectively based on pain relief and use of rescue medication data collected at six hours postoperatively. The majority of this evidence (five out of six trials) compared ibuprofen 400 mg with paracetamol 1000 mg, these are the most frequently prescribed doses in clinical practice. The novel combination drug is showing encouraging results based on the outcomes from two trials when compared to the single drugs.

Tranexamic acid reduces intraoperative blood loss in orthognathic surgery

Data sourcesMedline, Embase and the reference lists of identified articles were also scanned for relevant papers.Study selectionOnly randomised controlled trials in English were considered.Data extraction and synthesisTwo reviewers extracted data independently and study quality was assessed using the Jadad score. Meta-analysis was conducted.ResultsFour RCTs with a total of 183 patients were included. Intraoperative blood loss in the tranexamic acid group was statistically reduced (weighted mean difference [WMD] = −93.56, 95% CI = −132.59-54.52, P < .00001). No statistical difference was seen in the postoperative levels of haemoglobin and haematocrit (WMD = 0.50, 95% CIs = −0.43-1.43, P = .29 and WMD = 0.18, 95% CIs = −1.64-1.99, P = .85, respectively).ConclusionsThis meta-analysis confirms that tranexamic acid can effectively reduce intraoperative blood loss in orthognathic surgery, especially by intravenous administration. But tranexamic acid cannot affect postoperative levels of haemoglobin and haematocrit.