Clovis Mariano Faggion

The Frequency of Peri-Implant Diseases: A Systematic Review and Meta-Analysis

BACKGROUND The peri-implant diseases, namely peri-implant mucositis and peri-implantitis, have been extensively studied. However, little is known about the true magnitude of the problem, owing mainly to the lack of consistent and definite diagnostic criteria used to describe the condition. The objective of the present review is to systematically estimate the overall frequency of peri-implant diseases in general and high-risk patients. METHODS The systematic review is prepared according to the Meta-analysis of Observational Studies in Epidemiology statement. Studies were searched in four electronic databases, complemented by manual searching. The quality of the studies was assessed according to Strengthening the Reporting of Observational Studies in Epidemiology, and the data were analyzed using statistical software. RESULTS Of 504 studies identified, nine studies with 1,497 participants and 6,283 implants were included. The summary estimates for the frequency of peri-implant mucositis were 63.4% of participants and 30.7% of implants, and those of peri-implantitis were 18.8% of participants and 9.6% of implants. A higher frequency of occurrence of peri-implant diseases was recorded for smokers, with a summary estimate of 36.3%. Supportive periodontal therapy seemed to reduce the rate of occurrence of peri-implant diseases. CONCLUSIONS Peri-implant diseases are not uncommon following implant therapy. Long-term maintenance care for high-risk groups is essential to reduce the risk of peri-implantitis. Informed consent for patients receiving implant treatment must include the need for such maintenance therapy.

Do bone grafts or barrier membranes provide additional treatment effects for infrabony lesions treated with enamel matrix derivatives? A network meta‐analysis of randomized‐controlled trials

BACKGROUND/AIM Network meta-analyses of randomized-controlled trials were undertaken to investigate whether enamel matrix derivatives (EMD) in conjunction with other regenerative materials yield better treatment outcomes than EMD alone in the treatment of infrabony defects > or =3 mm. MATERIAL AND METHODS A literature search was conducted using the Medline, EMBASE, LILACS and CENTRAL databases up to and including December 2008. Treatment outcomes were changes in probing pocket depth (PPD), clinical attachment level (CAL) and infrabony defect depth. Different types of bone grafts (or barrier membranes) were first treated as a group and then separately. RESULTS Twenty-eight studies were included in the review. EMD plus bone grafts and EMD plus membranes attained 0.24 mm [95% high probability density (HPD) intervals: -0.38, 0.65] and 0.07 mm (95% HPD intervals: -1.26, 1.04) more PPD reduction than EMD alone, respectively. For CAL gain, EMD plus bone grafts and EMD plus membranes attained 0.46 mm (95% HPD intervals: -0.17, 0.83) and 0.15 mm (95% HPD intervals: -1.37, 0.30), respectively. When different types of bone grafts and barrier membranes were treated separately, EMD with bovine bone grafts showed greater treatment effects. CONCLUSION There was little evidence to support the additional benefits of EMD in conjunction with other regenerative materials.

Effect of glycine powder air-polishing on the gingiva

OBJECTIVES Safety and efficacy of glycine powder air-polishing (GPAP) in removing subgingival biofilm have been previously demonstrated. The hypothesis that GPAP results in less gingival erosion than sodium bicarbonate air-polishing (SBAP) or hand-instrumentation was assessed. MATERIAL AND METHODS In each of 10 patients, eight teeth with a residual probing depth of at least 5 mm following initial periodontal therapy were randomly assigned to the following interventions: GPAP (test), SBAP (positive control), hand-instrumentation (positive control), or no treatment (negative control). In each group, gingival biopsies were taken immediately after instrumentation and one 14 days later. Damaged gingival epithelium (GE) was assessed by light microscopy and quantified by a histological score (values 1-4). Differences between groups were evaluated using the marginal homogeneity test. RESULTS GPAP resulted in minor erosions of the GE (scores 1 and 2), whereas positive control specimens displayed moderate to severe erosions (scores 2-4). Differences between GPAP and positive controls were significant (p<0.05). Fourteen days following instrumentation GE under assessment was found to be intact in all groups. CONCLUSION The data indicated that GPAP results in less gingival erosion than SBAP or hand instrumentation, further supporting the safety of this new debridement technique.

Risk factors that may modify the innate and adaptive immune responses in periodontal diseases

Plaque-induced periodontal diseases occur in response to the accumulation of dental plaque. Disease manifestation and progression is determined by the nature of the immune response to the bacterial complexes in plaque. In general, predisposing factors for these periodontal diseases can be defined as those factors which retain or hinder the removal of plaque and, depending upon the nature of the immune response to this plaque, the disease will either remain stable and not progress or it may progress and result in chronic periodontitis. In contrast, modifying factors can be defined as those factors that alter the nature or course of the inflammatory lesion. These factors do not cause the disease but rather modify the chronic inflammatory response, which, in turn, is determined by the nature of the innate and adaptive immune responses and the local cytokine and inflammatory mediator networks. Chronic inflammation is characterized by vascular, cellular and repair responses within the tissues. This paper will focus on how common modifying factors, such as smoking, stress, hormonal changes, diabetes, metabolic syndrome and HIV/AIDS, influence each of these responses, together with treatment implications. As treatment planning in periodontics requires an understanding of the etiology and pathogenesis of the disease, it is important for all modifying factors to be taken into account. For some of these, such as smoking, stress and diabetic control, supportive health behavior advice within the dental setting should be an integral component for overall patient management.

Critical appraisal of AMSTAR: challenges, limitations, and potential solutions from the perspective of an assessor

BackgroundSystematic reviews are pivotal components in the development of evidence-based clinical guidelines. To evaluate the methodological quality of these systematic reviews, several tools have been proposed. Among them, the assessment of multiple systematic reviews (AMSTAR) checklist is probably used most frequently. This tool comprises 11 items related to the steps taken when conducting a systematic review, and it is claimed to have good face and content validity. The objective of this debate paper was twofold: (a) to critically evaluate the ability of all AMSTAR checklist items to adequately determine the methodological quality of a systematic review; and (b) to describe difficulties regarding interpretation of the checklist, and provide potential solutions for these difficulties.DiscussionSome items of the AMSTAR checklist seem to assess the quality of reporting of a systematic review more than its methodological quality. For example, item 7 may not “capture” the true methodological quality of primary studies included in the systematic review. Item 10 does not likely result in the collection of in-depth information on the presence of publication bias in the systematic review. Furthermore, some items may be difficult to interpret, hindering accurate assessment. For example, item 5 does not explicitly indicate whether a list of documents excluded in each phase of selection (i.e., after evaluation of titles and abstracts, and after full-text assessment) should be reported.SummaryThe present debate paper evaluated and discussed some methodological limitations of the AMSTAR checklist, as well as challenges involved in evaluation of the checklist’s items. Several suggestions are also made to optimize the use of this checklist. The information in this paper may stimulate further discussion among systematic reviewers, methodologists and clinicians.

Network Meta-Analysis for Evaluating Interventions in Implant Dentistry: The Case of Peri-Implantitis Treatment

BACKGROUND/AIM Evidence from head-to-head comparison trials on peri-implantitis treatment is limited, and it is therefore impossible to conduct a direct meta-analysis. We propose an alternative statistical method, network meta-analysis, for evidence synthesis, which enables to compare the results of multiple treatments. METHODS We searched, in triplicate, for randomized controlled trials (RCTs) and controlled trials in the PubMed, Cochrane Central Register of Controlled Trials, Clinicaltrials.gov, and Latin American and Caribbean Health Sciences Literature databases up to and including August 2010. We also conducted a manual search of the reference lists regarding published systematic reviews and searched for gray literature in OpenSIGLE. We assessed changes in clinical attachment level (CAL) and pocket probing depth (PPD) after nonsurgical and surgical treatments of peri-implantitis. The risk of bias of selected studies was determined by the use of specific criteria, and it was performed in triplicate and independently. We used multilevel mixed modeling to perform the network meta-analysis and Markov Chain Monte Carlo simulation to obtain confidence intervals for the fixed and random effects. RESULTS Eleven studies were included in the review. All RCTs are at unclear or high risk of bias. Surgical therapy in conjunction with bone grafts and non-resorbable membranes achieved 3.52 mm greater PPD reduction than nonsurgical therapy alone, 95% high-probability density (HPD) intervals: -0.19, 6.81. Surgical treatment in conjunction with bone grafts and resorbable membranes achieved 2.80 mm greater CAL gain than nonsurgical therapy alone, 95% HPD intervals: -0.18, 5.59. CONCLUSION Surgical procedures in peri-implantitis treatment achieve more PPD reduction and CAL gain than nonsurgical approaches. Nevertheless, these results should be interpreted with caution because of the limited number of studies included and their low methodological quality. Network meta-analysis is a useful statistical methodology for evidence synthesis and to summarize the strength and limitation in the current evidence.

An economic evaluation of different sinus lift techniques.

PURPOSE To identify the most cost-effective approach to sinus lifting on the basis of currently available evidence. METHODS We incorporate the costs and clinical outcomes of nine different sinus lift techniques within a decision tree model in which costs are based on insurance regulations in Germany and health outcomes follow two recent meta-analyses. The most cost-effective treatment option is identified on the basis of the maximum net benefit criterion. Uncertainties regarding health outcomes are incorporated via probabilistic sensitivity analysis based on Monte-Carlo simulation. RESULTS When there are no financial restrictions, the optimum treatment strategy is the lateral approach with autogenous particulate bone and a resorbable membrane. When, however, monetary resources for sinus-floor elevation are scarce, the most cost-effective option is the transalveolar technique without bone grafting. Only if relatively high costs can be afforded or if initial bone height at implant site is below 5 mm is the maximum net benefit achieved by lateral approaches. CONCLUSIONS On the basis of currently available evidence, the transalveolar technique is advisable when monetary resources for sinus-floor elevation are scarce and initial bone height is sufficiently high. Lateral approaches are primarily recommended for lower pre-operative bone heights.

Dental service utilization by Europeans aged 50 plus

OBJECTIVES To describe variations in the utilization of dental services by persons aged 50+ from 14 European countries and to identify the extent to which such variations are attributable to differences in oral health need and in accessibility of dental care. METHODS We use data from the Survey of Health, Ageing, and Retirement in Europe (SHARE Waves 2 and 3) and estimate a series of multivariate logistic regression models to analyze variations in dental service utilization (overall dental attendance, preventive treatment and/or operative treatment, dental attendance in early life years) RESULTS Overall dental attendance and incidence of solely preventive treatment are comparatively high in the Netherlands, Sweden, Denmark, Germany, and Switzerland. In contrast, overall dental attendance is relatively low in Spain, Italy, France, Greece, Poland, and Ireland. Moreover, a high incidence of solely operative treatment is observed in Austria, Italy, and France, whereas in the Netherlands, Sweden, Denmark, Switzerland, and Ireland, the incidence of solely operative treatment is comparably low. By and large, these variations persist even when controlling for cross-country differences in oral health need and in accessibility of dental care. CONCLUSIONS In comparison with other European regions, there is a tendency toward more frequent and preventive dental treatment of the elderly populations residing in Scandinavia and Western Europe. Such utilization patterns appear only partially attributable to differences in need for and accessibility of dental care.

A cost‐effectiveness evaluation of enamel matrix derivatives alone or in conjunction with regenerative devices in the treatment of periodontal intra‐osseous defects

PURPOSE To identify the most cost-effective approach to treatment of infrabony lesions with enamel matrix derivatives (EMD). METHODS We incorporated costs and clinical outcomes of 12 different treatment techniques (including flap operation, EMD alone, and EMD in association with other reconstructive devices) within a decision tree model in which costs were based on insurance regulations in Germany and health outcomes followed a recent meta-analysis. The most cost-effective treatment option was identified on the basis of the maximum net benefit criterion. RESULTS Treatment techniques using EMD were cost-efficient if the decision makers willingness-to-pay (WTP) was at least €150-175 per incremental mm of pocket probing depth reduction and clinical attachment level gain, respectively (1-year perspective). When EMD was affordable, the maximum net benefit was achieved by treatment with EMD in conjunction with bioactive glass or bovine bone substitutes. Additional application of platelet-rich plasma (PRP) or a resorbable membrane came at relatively high costs. CONCLUSIONS If EMD use is indicated, EMD in conjunction with either bioactive glass or bovine bone substitutes is more cost-effective than EMD alone. The additional use of PRP or a resorbable membrane may only be justifiable when monetary resources for treatment are very generous.

Comparison of the effects of treatment of peri-implant infection in animal and human studies: systematic review and meta-analysis

OBJECTIVE The main objective of this systematic review is to compare the effects of treatment of peri-implant infection between animal and human studies. MATERIAL AND METHODS A literature search was conducted using the Medline, Cochrane Central Register of Controlled Trials, and Latin American and Caribbean Health Sciences Literature databases up to and including May 2008. In addition, bibliographies of systematic reviews on peri-implant diseases were searched manually. Non-surgical and surgical treatments of peri-implantitis/mucositis in animal models or human studies were compared. Meta-analysis was conducted to investigate the difference between the reported treatment effects in animal and human studies. Changes in probing pocket depth (PPD) and probing attachment level (PAL) from baseline measurements were used as measures of outcome. Single-level and multilevel meta-regression analysis was performed by taking into account the different follow-up times of the studies included. RESULTS The single-level and multilevel random-effects meta-analysis showed that the difference in PPD reduction [0.31 mm, 95% confidence interval (CI): -0.27, 0.88] and in PAL gain (0.21 mm, 95% CI: -0.47, 0.88) between animal and human studies was not statistically significant. The random-effects meta-regression suggested that studies with longer follow-up times revealed greater PPD reduction (0.25 mm per month, 95% CI: 0.14, 0.35). However, when the different follow-up times were taken into account, these differences became greater. Substantial heterogeneity between studies was found in the meta-analyses (I(2)=97.6% for animal studies and 99.9% for human studies). CONCLUSION There was great heterogeneity between human and animal studies in terms of study designs and treatment procedures. Therefore, the results from this meta-analysis should be interpreted with caution. Heterogeneity between studies and its causes merit further investigations.