Elena Figuero

Surgical protocols for ridge preservation after tooth extraction. A systematic review

OBJECTIVE This systematic review aims to evaluate the scientific evidence on the efficacy in the surgical protocols designed for preserving the alveolar ridge after tooth extraction and to evaluate how these techniques affect the placement of dental implants and the final implant supported restoration. MATERIAL AND METHODS A thorough search in MEDLINE-PubMed, Embase and the Cochrane Central Register of controlled trials (CENTRAL) was conducted up to February 2011. Randomized clinical trials and prospective cohort studies with a follow-up of at least 3 months reporting changes on both the hard and soft tissues (height and/or width) of the alveolar process (mm or %) after tooth extraction were considered for inclusion. RESULTS The screening of titles and abstracts resulted in 14 publications meeting the eligibility criteria. Data from nine of these 14 studies could be grouped in the meta-analyses. Results from the meta-analyses showed a statistically significant greater ridge reduction in bone height for control groups as compared to test groups (weighted mean differences, WMD = -1.47 mm; 95% CI [-1.982, -0.953]; P < 0.001; heterogeneity: I(2) = 13.1%; χ(2) P-value = 0.314) and a significant greater reduction in bone width for control groups compared to the test groups (WMD = -1.830 mm; 95% CI [-2.947, -0.732]; P = 0.001; heterogeneity: I(2) = 0%; χ(2) P-value = 0.837). Subgroup analysis was based on the surgical protocol used for the socket preservation (flapless/flapped, barrier membrane/no membrane, primary intention healing/no primary healing) and on the measurement method utilized to evaluate morphological changes. Meta-regression analyses demonstrated a statistically significant difference favoring the flapped subgroup in terms of bone width (meta-regression; slope = 2.26; 95% IC [1.01; 3.51]; P = 0.003). CONCLUSIONS The potential benefit of socket preservation therapies was demonstrated resulting in significantly less vertical and horizontal contraction of the alveolar bone crest. The scientific evidence does not provide clear guidelines in regards to the type of biomaterial, or surgical procedure, although a significant positive effect of the flapped surgery was observed. There are no data available to draw conclusions on the consequences of such benefits on the long-term outcomes of implant therapy.

Detection of Periodontal Bacteria in Atheromatous Plaque by Nested Polymerase Chain Reaction

BACKGROUND In recent years, increasing evidence regarding the potential association between periodontal diseases and cardiovascular diseases has been identified. The available evidence underlines the importance of detecting periodontal pathogens on atheromatous plaque as the first step in demonstrating the causal relationship between the two conditions. The main aim of this investigation is to detect periodontitis-associated bacteria from carotid artery atheromatous plaque from patients who received an endarterectomy using strict sample procurement and laboratory procedures. METHODS Atheromatous plaque from endarterectomies from carotid arteries were scraped and homogenized, and bacterial DNA was extracted. To obtain a representative concentration of amplicons, two amplifications of the bacterial 16S ribosomal-RNA gene were carried out for each sample with universal eubacteria primers by a polymerase chain reaction (PCR). A nested PCR with specific primers for the target bacteria was performed next. Statistical tests included the χ(2) test. RESULTS Forty-two atheromatous plaque were analyzed. All of them were positive for ≥1 target bacterial species. The bacterial species most commonly found was Porphyromonas gingivalis (78.57%; 33 of 42), followed by Aggregatibacter actinomycetemcomitans (previously Actinobacillus actinomycetemcomitans) (66.67%; 28 of 42), Tannerella forsythia (previously T. forsythensis) (61.90%; 26 of 42), Eikenella corrodens (54.76%; 23 of 42), Fusobacterium nucleatum (50.00%; 21 of 42), and Campylobacter rectus (9.52%; four of 42). The simultaneous presence of various bacterial species within the same specimen was a common observation. CONCLUSION Within the limitations of this study, the presence of DNA from periodontitis-associated bacteria in carotid artery atheromatous plaque retrieved by endarterectomy is confirmed.

Primary prevention of peri-implantitis: managing peri-implant mucositis

AIMS Over the past decades, the placement of dental implants has become a routine procedure in the oral rehabilitation of fully and partially edentulous patients. However, the number of patients/implants affected by peri-implant diseases is increasing. As there are--in contrast to periodontitis--at present no established and predictable concepts for the treatment of peri-implantitis, primary prevention is of key importance. The management of peri-implant mucositis is considered as a preventive measure for the onset of peri-implantitis. Therefore, the remit of this working group was to assess the prevalence of peri-implant diseases, as well as risks for peri-implant mucositis and to evaluate measures for the management of peri-implant mucositis. METHODS Discussions were informed by four systematic reviews on the current epidemiology of peri-implant diseases, on potential risks contributing to the development of peri-implant mucositis, and on the effect of patient and of professionally administered measures to manage peri-implant mucositis. This consensus report is based on the outcomes of these systematic reviews and on the expert opinion of the participants. RESULTS Key findings included: (i) meta-analysis estimated a weighted mean prevalence for peri-implant mucositis of 43% (CI: 32-54%) and for peri-implantitis of 22% (CI: 14-30%); (ii) bleeding on probing is considered as key clinical measure to distinguish between peri-implant health and disease; (iii) lack of regular supportive therapy in patients with peri-implant mucositis was associated with increased risk for onset of peri-implantitis; (iv) whereas plaque accumulation has been established as aetiological factor, smoking was identified as modifiable patient-related and excess cement as local risk indicator for the development of peri-implant mucositis; (v) patient-administered mechanical plaque control (with manual or powered toothbrushes) has been shown to be an effective preventive measure; (vi) professional intervention comprising oral hygiene instructions and mechanical debridement revealed a reduction in clinical signs of inflammation; (vii) adjunctive measures (antiseptics, local and systemic antibiotics, air-abrasive devices) were not found to improve the efficacy of professionally administered plaque removal in reducing clinical signs of inflammation. CONCLUSIONS Consensus was reached on recommendations for patients with dental implants and oral health care professionals with regard to the efficacy of measures to manage peri-implant mucositis. It was particularly emphasized that implant placement and prosthetic reconstructions need to allow proper personal cleaning, diagnosis by probing and professional plaque removal.

Gingival changes during pregnancy: II. Influence of hormonal variations on the subgingival biofilm

AIM To determine whether the exacerbated gingival inflammation that develops in pregnant women is related to a change in the subgingival biofilm induced by the increase in hormone levels during pregnancy. MATERIAL AND METHODS This open cohort study included 48 pregnant and 28 non-pregnant women without periodontitis. Pregnant women were evaluated in the first, second and third trimester and at 3 months after delivery. Non-pregnant women were evaluated twice, with a 6-month interval, assessing microbiological, clinical and hormonal variables at each visit. Total anaerobic counts and frequency of detection and proportions were calculated. The Friedman test with the Bonferroni correction was used for intra-group comparisons and Mann-Whitney U-tests for inter-group assessment. Correlations were analysed by means of Spearmans rank correlation coefficient. RESULTS Proportions of the subgingival periodontal pathogens did not differ throughout pregnancy, although significant differences were found for all the pathogens after delivery. Porphyromonas gingivalis-positive patients presented an increase in gingival inflammation (p<0.001) that was not related to plaque. Correlations were found between maternal hormone levels and P. gingivalis and Prevotella intermedia. CONCLUSION Qualitative differences in periodontal pathogens were found from pregnancy to post-partum. Patients harbouring P. gingivalis presented and increased gingival inflammatory status.

Azithromycin as an adjunct to scaling and root planing in the treatment of Porphyromonas gingivalis‐associated periodontitis: a pilot study

OBJECTIVE To evaluate the clinical and microbiological effects of systemic azithromycin as an adjunct to scaling and root planing (SRP) in the treatment of Porphyromonas gingivalis-associated chronic periodontitis. METHODS Twenty-nine patients harbouring P. gingivalis were randomized into test and placebo groups. Test patients received SRP plus 500 mg of azithromycin per day (3 days), and control patients received SRP plus placebo. Clinical [plaque and bleeding indexes, probing pocket depth (PPD), clinical attachment level (CAL)] and microbiological data (four-sites pooled samples, processed by culture) were collected at baseline, and 1, 3 and 6 months, post-therapy. Clinical variables were compared by anova, and microbiological variables by chi-square, signed-rank and Wilcoxon tests. RESULTS Fifteen test and 11 placebo patients completed the study. Mean PPD decreased 0.34 mm [95% confidence interval (CI) 0.19-0.49] in the placebo and 0.80 mm (CI 0.57-1.04) in the test group after 6 months. For mean CAL gain, the correspondent figures were 0.29 (CI 0.08-0.49) and 0.76 (CI 0.46-1.05), respectively. The frequency of detection of P. gingivalis decreased significantly (p0.01) in the test group after 1, 3 and 6 months. CONCLUSIONS Within the limitations of this study, the adjunctive use of systemic azithromycin in the treatment of P. gingivalis periodontitis demonstrated significant clinical and microbiological benefits when compared with SRP plus placebo.

Effectiveness of Lateral Bone Augmentation on the Alveolar Crest Dimension A Systematic Review and Meta-analysis

Lateral ridge augmentation procedures are aimed to reconstruct deficient alveolar ridges or to build up peri-implant dehiscence and fenestrations. The objective of this systematic review was to assess the efficacy of these interventions by analyzing data from 40 clinical studies evaluating bone augmentation through either the staged or the simultaneous approach. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guideline for systematic reviews was used. The primary outcomes were the changes at reentry, in the ridge width, and in the vertical and horizontal dimensions of the peri-implant defect, measured in millimeters, in the staged and simultaneous approaches, respectively. The results of the meta-analysis showed, for the simultaneous approach, a statistically significant defect height reduction when all treatments were analyzed together (weighted mean difference [WMD] = −4.28 mm; 95% confidence interval: [CI] –4.88, –3.69; P < 0.01). The intervention combining bone replacement grafts with barrier membranes was associated with superior outcomes The most frequently used intervention was the combination of xenograft and bioabsorbable membrane. Similarly, for the staged approach, there was a statistically significant horizontal gain when all treatment groups were combined (WMD = 3.90 mm; 95% CI: 3.52, 4.28; P < 0.001). The most frequently used intervention was the use of autogenous bone blocks. Both treatment strategies led to high survival and success rates (>95%) for the implants placed on the regenerated sites. Nonexposed sites gained significantly more in the simultaneous and staged approaches (WMD = 1.1 and 3.1 mm).

Gingival changes during pregnancy: I. Influence of hormonal variations on clinical and immunological parameters

AIM To test whether exacerbated gingival inflammation in pregnancy is associated with increased salivary hormone levels and changes in gingival crevicular fluid (GCF) interleukin-1beta (IL-1beta) and prostaglandin-E2 (PGE2) levels. MATERIAL AND METHODS In this cohort study, 48 pregnant women without periodontitis were evaluated in the first, second, and third trimesters and at 3 months postpartum. Twenty-eight non-periodontitis non-pregnant women were evaluated twice, with a 6-month interval. Plaque and gingival indices (PlI, GI), salivary progesterone and estradiol and GCF IL-1beta and PGE2 levels were determined. anova for repeated measures or Friedmans test were used for intragroup analyses. Inter-group comparisons were analysed with t-test or Mann-Whitney U-test. Correlations were evaluated with Pearsons and Spearmans test. RESULTS Pregnant women showed an increase in GI (p<0.05) despite maintaining low PlI values. No changes in IL-1beta and PGE2 levels were observed during pregnancy. No significant correlation was found between the GI increase and salivary hormone levels. GI (p<0.05) and IL-1beta levels (p<0.001) were lower in non-pregnant than in pregnant women. CONCLUSIONS This study confirms the presence of an exacerbated gingival inflammation during pregnancy, but this phenomenon could not be associated with an increase in progesterone or estradiol or with changes in PGE2 or IL-1beta.

Surgical protocols for early implant placement in post‐extraction sockets: a systematic review

OBJECTIVES The aim of this systematic review was to evaluate the best timing for placing implants after tooth extraction, by comparing early vs. delayed implant placement and evaluating the hard and/or soft tissue ridge dimensional changes and the outcomes related with implant survival and prosthesis success. MATERIAL AND METHODS An online search of the main databases including The National Library of Medicine (MEDLINE via Pubmed), Embase and The Cochrane Central Register of Controlled Trials was conducted up to February 2011. Randomized controlled clinical trials (RCTs), prospective cohort studies and case-control retrospective studies, with a follow-up of at least 1 month after loading of dental implants, comparing: (i) early vs. delayed implant placement, (ii) augmentation vs. no augmentation at implant placement in early placed implants and/or (iii) the comparison of various augmentation procedures at early implant placement, were conducted. A hand search of relevant journals was also performed. Screening of eligible studies, assessment of their methodological quality and data extraction were conducted in duplicate by two independent reviewers. Authors of studies were contacted for clarification or missing information. RESULTS Eight studies were included, although meta-analysis could only be performed with the data from two studies comparing early vs. delayed implant. The percentage of bone height and bone width reduction favoured the early placement, with pooled mean difference between groups of 13.11% (95% CI: from 3.83 to 22.4; P = 0.057) and 19.85% (95% CI: from 13.85 to 25.81) respectively. Implant survival demonstrated a non-significant higher implant survival rate for the early group (RR = 1.02, 95% CI: 0.96-1.1).With regard to patient satisfaction, statistically significant differences between the groups in favour of the early group for overall satisfaction and appearance with the restoration were demonstrated at 2 years, although these differences were lost at 5 years. CONCLUSIONS Placement of dental implants at an early timing after tooth extraction may offer advantages in terms of soft and hard tissue preservation, when compared with a delayed protocol. Nevertheless, well-designed, high quality, randomized clinical trials, are needed, because the available evidence is today limited in terms of available studies and quality.

Management of peri‐implant mucositis and peri‐implantitis

Peri-implant diseases are defined as inflammatory lesions of the surrounding peri-implant tissues and include peri-implant mucositis (an inflammatory lesion limited to the surrounding mucosa of an implant) and peri-implantitis (an inflammatory lesion of the mucosa that affects the supporting bone with resulting loss of osseointegration). This review aims to describe the different approaches to manage both entities and to provide a critical evaluation of the evidence available on their efficacy. Therapy of peri-implant mucositis and nonsurgical therapy of peri-implantitis usually involve mechanical debridement of the implant surface using curettes, ultrasonic devices, air-abrasive devices or lasers, with or without the adjunctive use of local antibiotics or antiseptics. The efficacy of these therapies has been demonstrated for mucositis: controlled clinical trials show an improvement in clinical parameters, especially in bleeding on probing. For peri-implantitis, the results are limited, especially in terms of probing pocket-depth reduction. Surgical therapy of peri-implantitis is indicated when nonsurgical therapy fails to control the inflammatory changes. Selection of the surgical technique should be based on the characteristics of the peri-implant lesion. In the presence of deep circumferential and intrabony defects, surgical interventions should aim to provide thorough debridement, implant-surface decontamination and defect reconstruction. In the presence of defects without clear bony walls or with a predominant suprabony component, the aim of the surgical intervention should be the thorough debridement and the repositioning of the marginal mucosa to enable the patient to perform effective oral-hygiene practices, although this aim may compromise the esthetic result of the implant-supported restoration.

Systematic review of quality of reporting, outcome measurements and methods to study efficacy of preventive and therapeutic approaches to peri‐implant diseases

AIM To systematically review the literature and to assess the quality of reporting, outcome measurements and methods in both preventive and therapeutic approaches to peri-implant mucositis (PM) and peri-implantitis (PI). MATERIALS AND METHODS Randomized (RCT) and Controlled Clinical Trials (CCT), evaluating preventive or therapeutic interventions in patients with PM or PI, were identified through searching in electronic databases and in relevant journals. Reporting and methods were evaluated through an analysis of the risk of biases and quality score. Sub-analysis was performed in four subgroups: prevention of PM and PI, treatment of PM, and non-surgical and surgical treatment of PI. RESULTS Thirty-two trials (29 RCT) were identified as accomplishing inclusion criteria after full-text reading. Seven focused on prevention, and among those dealing with therapy, six were related to PM and 19 related to PI therapy (10 non-surgical and 9 surgical). Analysis found that quality of reporting and methods was generally low and surrogate outcomes were often chosen. CONCLUSIONS Current literature on PM and PI prevention and treatment does not allow extracting applicable clinical information. Quality of methods and reporting guidelines should be encouraged. In particular, ad hoc guidelines should be designed for peri-implant diseases.