Christian Bacci

Management of dental extraction in patients undergoing anticoagulant treatment. Results from a large, multicentre, prospective, case-control study.

Following favourable results from a previous study, a large, multicentre, prospective, case-control study was performed to further assess the incidence of bleeding complications after dental extraction in patients taking oral anticoagulant therapy (OAT). Four hundred fifty-one patients being treated with warfarin who required dental extraction were compared with a control group of 449 non-anticoagulated subjects undergoing the same procedure. In the warfarin-treated group, the oral anticoagulant regimen was maintained unchanged, such that the patients had an International Normalised Ratio ranging between 1.8 and 4, and local haemostatic measures (i.e. fibrin sponges, silk sutures and gauzes saturated with tranexamic acid) were adopted. All the procedures were performed in an outpatient setting. Seven bleeding complications occurred in the OAT group and four in the control group; the difference in the number of bleeding events between the two groups was not statistically significant (OR=1.754; 95% CI 0.510 - 6.034; p=0.3727). No post-operative late bleeds requiring hospitalisation and/or blood transfusions were recorded, and the adjunctive local haemostatic measures were adequate to stop the bleeding. The results of our protocol applied in this large, multicenter study show that dental extractions can be performed easily and safely in anticoagulated outpatients without any modification of the ongoing anticoagulant therapy, thus minimising costs and reducing discomfort for patients.

Toward the Validation of Visual Analogue Scale for Anxiety

Anxiety is a relevant problem in dental practice. The Visual Analogue Scale for Anxiety (VAS-A), introduced in dentistry in 1988, has not yet been validated in large series. The aim of this study is to check VAS-A effectiveness in more than 1000 patients submitted to implantology. The VAS-A and the Dental Anxiety Scale (DAS) were administered preoperatively to 1114 patients (459 males and 655 females, age 54.7 ± 13.1 years). Statistical analysis was conducted with Pearson correlation coefficient, the receiver operating characteristic (ROC) curve, and McNemar tests. A close correlation between DAS and VAS-A was found (r  =  0.57, P < .0001); the VAS-A thresholds of dental anxiety and phobia were 5.1 and 7.0 cm, respectively. Despite a significant concordance of tests in 800 cases (72%), disagreement was found in the remaining 314 cases (28%), and low DAS was associated with high VAS-A (230 cases) or vice versa (84 cases). Our study confirms that VAS-A is a simple, sensitive, fast, and reliable tool in dental anxiety assessment. The rate of disagreement between VAS-A and DAS is probably due to different test sensitivities to different components of dental anxiety. VAS-A can be used effectively in the assessment of dental patients, using the values of 5.1 cm and 7.0 cm as cutoff values for anxiety and phobia, respectively.

Safety of dental implant surgery in patients undergoing anticoagulation therapy: a prospective case-control study.

OBJECTIVES Several studies have described oral surgical procedures in patients receiving anticoagulant therapy, but no prospective studies on dental implant surgery during anticoagulant treatment are currently available, and only a limited number of case reports refer to endosseous dental implant treatment in these patients. In the setting of oral surgery, it has been suggested that anticoagulant treatment is not required when the International Normalized Ratio (INR) is <4 and local haemostatic measures are applied. The purpose of this preliminary study was to evaluate the incidence of bleeding complications following surgical implant therapy in a group of 50 consecutive patients receiving oral anticoagulant therapy (warfarin) without interruption or modifications to their therapy (group A). MATERIALS AND METHODS One hundred and nine otherwise healthy patients comparable for age, sex, extent and site of the implant surgical procedure formed the control group (group B). In both groups, a standard protocol of local haemostasis, including non-reabsorbable sutures and compressive gauzes soaked with tranexamic acid, was applied. Surgeons, blind to the group allocation, performed all the procedures in an outpatient setting. RESULTS Two and three late-bleeding complications were reported in group A and group B, respectively, without significant difference in the bleeding risk (relative risk = 1.45; P= 0.65; 95% confidence interval 0.2506-8.4271). These complications were managed using a compressive gauze soaked with tranexamic acid at the site of the surgical wound. CONCLUSION According to our preliminary results, local haemostasis in dental implant surgery is able to prevent bleeding complications in patients on oral anticoagulants, allowing these surgical procedures to be performed on an outpatient basis.

Randomized Split-Mouth Study on Postoperative Effects of Palmitoylethanolamide for Impacted Lower Third Molar Surgery

The aim of this study was to assess the efficacy of Normast 300 mg in reducing swelling and pain after the surgical extraction of impacted lower third molars. Materials and Methods. A randomized, split-mouth, single-blind study was conducted on 30 patients between 18 and 30 years of age requiring lower third molar extraction. Patients underwent bilateral extractions in a randomized sequence, one extraction being performed under Normast treatment. The Normast treatment involved 2 tablets a day for 15 days. The parameters assessed at each procedure were trismus, swelling, pain, NSAID consumption, postoperative complications, drug tolerability, and safety. The results obtained were processed using repeated measures analysis of variance. Results. Perceived postoperative pain was reportedly significantly milder on Normast treatment than control. The trend of the means differed over time (P < .0001) and between the two extraction groups (P < .0221). On the other hand, for edema and trismus, the trend differed over time for both groups but did not differ between the two groups. Discussion. Our analyses indicate that patients experienced significantly less postoperative pain when they were treated with Normast. Conclusions. Administering Normast improves the postoperative course—in terms of pain—after lower third molar extraction.

Intra‐oral bone harvesting: two methods compared using histological and histomorphometric assessments

AIM This study used morphometric analyses to compare two methods for the intra-oral harvesting of particulate bone: Mectron Piezosurgery® and the Meta Micross®. MATERIALS AND METHODS Twenty patients requiring bilateral germectomy of the lower third molars for orthodontic reasons were selected and a sample was harvested from each patient from a standardised donor site (the cortical bone in the area of the retromolar triangle). Ten samples were obtained for each method. The particulate collected were subjected to a histological examination and the samples were analysed considering the following parameters: the mean surface area of fragments, the mean surface area considered vital and the mean surface area considered non-vital, the mean percentage of area considered vital and the mean percentage of area considered non-vital, the mean number of normal osteocytes and the mean number of osteocytes with morphological changes identified per unit area (600,000 μm(2)). The results were analysed, calculating the mean and the corresponding standard deviations, and testing their significance using Students t-test, and plotted in graphs. RESULTS Mectron Piezosurgery® produced significantly larger particles (P<0.05) than the Meta Micross®, with a larger mean surface area considered vital and a significantly larger (P<0.05) surface area considered non-vital. Mectron Piezosurgery® also produced a smaller mean percentage of area considered vital (64.83%) and a larger mean percentage of area considered non-vital (35.17%) by comparison with the Meta Micross® (75.34% and 24.66%, respectively). The data also showed that the two methods produce a similar quantity of empty lacunae, and that the Mectron Piezosurgery® produces a larger quantity of osteocytes. CONCLUSIONS The analyses conducted demonstrated that the particulate collected with the Meta Micross® had a smaller mean surface area of the fragments and a smaller surface area of bone considered non-vital than in the particulate collected using Mectron Piezosurgery®.

Rehabilitation With Implants After Bone Lid Surgery in the Posterior Mandible

Bone defects are often secondary to alveolar disease removal. Creating a bone lid with piezosurgery is a valid method to preserve the alveolar bone. A careful and precise osteotomy associated with a firm placement of the bone lid in its original position enables better bone healing, thus allowing for the delayed insertion of dental implants at the operated site with no need for any bone augmentation procedures. The aim of this technical note is to present the application of the bone lid surgery in the posterior mandible before dental implant rehabilitation.

In Vitro Assessment with the Infrared Thermometer of Temperature Differences Generated During Implant Site Preparation: The Traditional Technique Versus the Single‐Drill Technique

Purpose To assess in vitro, using an infrared (IR) thermometer, temperature changes generated at implant sites by osteotomies involving two different drilling methods (with multiple drills versus only one) and to measure the influence of irrigation on the temperature variation. Materials and Methods Forty bone samples (from bovine rib) were divided into two groups of 20. Osteotomies were performed in group A with four drills, using the standard method (Leone Dental Implant System, final diameter 3.5 mm), and in group B with a single drill (Zero1 Drill, Leone Dental Implant System 3.5 mm diameter). In each group, half of the osteotomies were performed with irrigation (subgroups A1 and B1) and the other half without irrigation (subgroups A2 and B2). Two osteotomies were performed on each sample, using four different-sized drills according to the standard technique on one side and using a single drill on the other side. The starting temperature (T0) and the maximum temperature (Tmax) reached in the bone were measured. Comparisons of ΔT were drawn between subgroups A1 and B1 and between subgroups A2 and B2. The data were analyzed using Students t-test (with 95% confidence interval). Results The mean difference identified between the temperature produced with the last drill used in the traditional technique and that produced with the single drill was 0.3150 ± 1.0194°C when irrigation was used (group A1 vs group B1; not statistically significant). The mean difference between the temperature produced with the last drill of the traditional technique and that produced with the single drill was −0.3526 ± 0.5232°C when irrigation was not used (group A2 vs group B2; statistically significant). Conclusions The single-drill method induced a significantly greater variation in temperature than the traditional method, but only when irrigation was used; without any irrigation, the difference in the temperature variation generated by the two methods was not statistically significant. In any case, bone heating during the osteotomy never exceeded 2°C and was clinically irrelevant, as thermal damage to bone has only been reported in the literature for temperatures beyond 47°C persisting for more than one minute.PURPOSE To assess in vitro, using an infrared (IR) thermometer, temperature changes generated at implant sites by osteotomies involving two different drilling methods (with multiple drills versus only one) and to measure the influence of irrigation on the temperature variation. MATERIALS AND METHODS Forty bone samples (from bovine rib) were divided into two groups of 20. Osteotomies were performed in group A with four drills, using the standard method (Leone Dental Implant System, final diameter 3.5 mm), and in group B with a single drill (Zero1 Drill, Leone Dental Implant System 3.5 mm diameter). In each group, half of the osteotomies were performed with irrigation (subgroups A1 and B1) and the other half without irrigation (subgroups A2 and B2). Two osteotomies were performed on each sample, using four different-sized drills according to the standard technique on one side and using a single drill on the other side. The starting temperature (T0 ) and the maximum temperature (Tmax ) reached in the bone were measured. Comparisons of ΔT were drawn between subgroups A1 and B1 and between subgroups A2 and B2. The data were analyzed using Students t-test (with 95% confidence interval). RESULTS The mean difference identified between the temperature produced with the last drill used in the traditional technique and that produced with the single drill was 0.3150 ± 1.0194°C when irrigation was used (group A1 vs group B1; not statistically significant). The mean difference between the temperature produced with the last drill of the traditional technique and that produced with the single drill was -0.3526 ± 0.5232°C when irrigation was not used (group A2 vs group B2; statistically significant). CONCLUSIONS The single-drill method induced a significantly greater variation in temperature than the traditional method, but only when irrigation was used; without any irrigation, the difference in the temperature variation generated by the two methods was not statistically significant. In any case, bone heating during the osteotomy never exceeded 2°C and was clinically irrelevant, as thermal damage to bone has only been reported in the literature for temperatures beyond 47°C persisting for more than one minute.

Influence of Root Canal Posts on the Reattachment of Fragments to Endodontically Treated Fractured Incisors: An in vitro Experimental Comparison.

OBJECTIVE The aim of this study was to establish the benefits of inserting a fiberglass post when bonding tooth fragments after complicated coronal fractures. METHODS Thirty bovine incisors were randomly assigned to three groups: a control group of intact teeth (A), and two experimental groups (B and C). Coronal fragments were cut from the teeth in groups B and C, which then underwent root canal treatment, inserting posts in the teeth in group C. The coronal fragments were bonded to the teeth in both experimental groups using the same materials and technique, then the specimens were submitted to mechanical loading until fracture. RESULTS The specimens in the experimental groups had a lower resistance to mechanical loading than the intact teeth. The mean failure load was: 352.77 (SD ± 62.22) N in group A, 151.04 (SD ± 45.76) N in group B, and 168.61 (SD ± 33.59) N in group C. The difference between group A and the other two groups was statistically significant (analysis of variance test: p < 0.0001), whereas there was no statistically significant difference in the force needed to fracture the teeth in groups B and C (Tukeys test: p = 0.34). When the failure mode under loading was examined, the fractures in group C never involved new tooth substance beneath the adhesion interface, whereas in group B, this was only true in one in two cases. CONCLUSIONS Inserting a post does not significantly improve the strength of restored teeth, but it may result in a more favorable fracture mode. CLINICAL SIGNIFICANCE Within the limitations of this in vitro study, reattaching the fragment of a fractured tooth does not seem to restore the tooth to its original load resistance. The findings of this study indicate that inserting a fiberglass post for reinforcement purposes in fractured teeth undergoing root canal treatment is unable to significantly improve their load-bearing capacity by comparison with teeth repaired without inserting a post. However, the results of the present study suggest that inserting a post may result in a more favorable fracture mode in the event of further trauma.

Complex dental extractions in a patient with severe haemophilia A and inhibitors treated with activated prothrombin complex concentrate

Inhibitors that neutralise the function of clotting factor VIII occur in up to 30% of patients with severe haemophilia A1. The development of these allo-antibodies is one of the most serious complications of haemophilia and bleeding episodes become refractory to standard treatment. Among patients whose inhibitor titre is greater than 5 Bethesda units (BU), factor VIII (FVIII) replacement, even at very high doses, is generally ineffective at stopping the bleeding. Consequently, alternative therapeutic approaches are necessary: these consist primarily of using inhibitor bypassing agents. Two bypassing products are currently available on the market: factor eight inhibitor bypassing activity (FEIBA; Baxter Healthcare Corporation, Vienna, Austria), which is an activated prothrombin complex concentrate (aPCC), and recombinant activated factor VII (rFVIIa; Novoseven Novo Nordisk A/S Bagsvaerd, Denmark). The two bypassing agents achieve haemostasis through different mechanisms, bypassing the FVIII-dependent step in the coagulation cascade and promoting haemostasis by enhancing the generation of thrombin. Both products are used for controlling bleeding during surgery in haemophilic patients with inhibitors, though their efficacy may differ. As each bleeding episode is unique to each patient, each surgical operation and site of bleeding, clear guidelines on the treatment of patients are lacking and indications come from suggestions of experts in the field2. With reference to dental surgery in haemophilic patients with high inhibitor titre treated with FEIBA, few case reports have been published in the literature3,4. We proposed a treatment protocol consisting in anaesthesia without vasoconstriction, sutures associated with local haemostatic measures, such as oxidised cellulose sponges and tranexamic acid, and administration of factor replacement, which proved extremely effective in non-haemophiliac patients undergoing tooth extractions5. The same protocol, modified by the use of a bypassing agent instead of FVIII replacement therapy, was applied in the patient described below.

Is the median palatine cyst a distinct entity

T s h In 1992, the World Health Organization (WHO) published the second, revised edition of “Histological Typing of Odontogenic Tumours,” following the first edition published in 1971. It was the first authoritative and useful guide to the uneasy classification of odontogenic tumors. In this official position of the WHO, we can read the following: “Midline cysts of the maxilla and mandible, previously thought to be entities derived from epithelium entrapped during the fusion of embryonic facial processes. The existence of these cysts as entities derived in this way has been seriously questioned by embryologists and pathologists. It is now felt that those in the maxilla represent a posterior extension of a nasopalatine duct cyst in the case of a median palatine cyst and an anterior extension in the case of a median alveolar cyst. Occasionally, a cyst in the median alveolar position is a keratocyst. Cysts in the midline of the mandible may be radicular cysts, lateral periodontal cysts or odontogenic keratocysts.” Can we now assume that median palatine cysts (MPCs) are not a separate entity? Despite this, 3 cases of median maxillary cyst (or palatal median cyst) were reported in the literature after 1992. In the most recent case, published by Manzon et al in 2009, the authors stated that MPC s an uncommon nonodontogenic cyst, because it