Margareta Hultin

Treatment outcome of immediately loaded implants installed in edentulous jaws following computer‐assisted virtual treatment planning and flapless surgery

OBJECTIVES The objective was to evaluate the outcome of immediately loaded implants installed in edentulous jaws following computer-assisted virtual treatment planning combined with flapless surgery. MATERIAL AND METHODS Twenty-nine edentulous patients (9 females, 20 males, mean age of 71.5 years) were treated using the Nobel Guide protocol for surgical planning, fixture installation and immediate functioning of a prefabricated fixed implant prosthesis. One hundred and seventy-six fixtures were installed to support 21 maxillary and 10 mandibular reconstructions. Patients were followed for up to 44 months. RESULTS Nineteen out of 176 fixtures were lost between 2 and 18 months after installation. Fixture survival rate was 89% (92% maxilla, 83% mandible). Implant-supported suprastructures remained stable during the follow-up period in 26 out of 31 jaws (90% maxilla, 70% mandible). Surgical or technical complications occurred in 42% of treated cases. Misfit of abutment-bridge appeared in five cases, resulting in disconnection of the bridge in two patients where fixtures were left for unloaded healing. Fixture losses resulted in the removal of the suprastructure in three patients, who returned to removable dentures. Extensive adjustments of occlusion were made in 10% of the immediately connected bridges. Radiographic bone defects developed in three patients after drilling, which appeared in two cases after anchor-pin drilling in the maxilla and another in a severely resorbed mandible. CONCLUSION The patients post-operative discomfort such as swelling and pain was almost negligible. However, compared to conventional protocols, the occurrences of surgical and technical complications were higher, and thus this method must still be regarded to be in an exploratory phase.

Risk factors for atherosclerosis in cases with severe periodontitis

AIM Studies have reported on an association between cardiovascular disease (CVD) and periodontitis. The purpose of this case-control study was to provide an insight into this association by determining the plasma levels of some risk markers for CVD in cases with periodontitis. MATERIALS AND METHODS Sixty-eight cases with periodontitis, mean age 53.9 (SD 7.9) years, and 48 randomly selected healthy controls, mean age 53.1 (SD 7.9) years, were investigated. Fasting blood plasma was analysed for glucose, lipids, markers systemic inflammation, cytokines and antibodies against heat shock proteins (Hsp). The associations between periodontitis and the various substances analysed in plasma were calculated using a multivariate logistic regression model, which compensated for age, gender, smoking and body mass index. RESULTS The regression analyses revealed a significant association between periodontitis and high levels of C-reactive protein (CRP) [odds ratio (OR) 4.0, confidence interval (CI) 1.4-11.4] and fibrinogen (OR 8.7, CI 2.6-28.4), IL-18 (OR 6.5, CI 2.2-19.5), and decreased levels of IL-4 (OR 0.12, CI 0.0-0.5). The study showed increased levels of antibodies against Hsp65 (OR 2.8, CI 1-7.6) and 70 (OR 2.9, CI 1.1-7.8) and decreased levels of antibodies against Hsp60 (OR 0.3, CI 0.1-0.8). CONCLUSIONS Periodontitis was associated with increased levels of CRP, glucose, fibrinogen and IL-18, and with decreased levels of IL-4.

Periodontal treatment influences risk markers for atherosclerosis in patients with severe periodontitis.

This study investigated the effect of mechanical infection control for periodontitis and periodontal surgery on the prevalence of well-established risk factors for atherosclerosis, and plasma levels of cytokines, antibodies against heat shock proteins and markers of systemic inflammation. Sixty-eight patients between 39 and 73 years of age with severe periodontitis who had been referred to four specialist periodontology clinics in Sweden were investigated. A fasting venous blood sample was taken at baseline and additional samples were collected after 3 and 12 months. A total of 54 patients underwent periodontal treatment. The periodontal treatment was successful, as pathogenic gingival pockets decreased significantly. Plasma glucose, lipids and markers of systemic inflammation were not significantly altered after 3 months. One year after the initial treatment, HDL-C concentrations were significantly increased (Delta0.08mmol/L) whereas LDL-C concentrations decreased (Delta0.23mmol/L). Haptoglobin concentrations were also lower. Interleukin-18 and interferon-gamma levels were also lower after 12 months (60ng/L (-23%) and 11ng/L (-97%) respectively). Treatment had no effect on plasma levels of IgA, IgG1, IgG2 antibodies against heat shock proteins. In conclusion, this study indicates that standard treatment for periodontal disease induces systemic changes in several biochemical markers that reflect the risk for atherosclerosis.

Clinical advantages of computer‐guided implant placement: a systematic review

OBJECTIVES To systematically scrutinize the current scientific literature regarding the clinical advantages of computer guidance of implant placement. MATERIALS AND METHODS Four electronic databases were searched using specified indexing terms. The reference lists of publications were also searched manually. For inclusion, publications had to meet pre-established criteria. RESULTS The searches yielded 1028 titles and abstracts. After data extraction and interpretation, 28 publications and 2 systematic reviews remained for inclusion. Fifteen studies were prospective observational and four were retrospective observational. Nine studies included a control group (controlled clinical trials) of which seven were prospective and two retrospective. Only three of the prospective studies were randomized (RCTs). A total of 852 patients were treated with 4032 implants using computer-guided implant surgery. The number of patients included in each study ranged from 6 to 206. The age ranged from 16 to 92 years and the follow-up period varied between 1 and 49 months. CONCLUSIONS The limited scientific evidence available suggests that guided placement has at least as good implant survival as conventional protocols. However, several unexpected procedure-linked adverse events during guided implant placement indicate that the clinical demands on the surgeon were no less than those during conventional placement. A clinical advantage with flapless guided surgery is that the technique is likely to decrease pain and discomfort in the immediate postoperative period.

Soft Tissue Conditions and Marginal Bone Changes around Immediately Loaded Implants Inserted in Edentate Jaws Following Computer Guided Treatment Planning and Flapless Surgery: A ≥1‐Year Clinical Follow‐Up Study

BACKGROUND Evaluation of the clinical conditions following computer guided treatment planning and flapless surgery is still limited. OBJECTIVES The objective was to evaluate the soft tissue conditions and marginal bone changes after 1 year of function around immediately loaded implants inserted in edentate jaws following computer guided treatment planning and flapless surgery. MATERIAL AND METHODS Twenty-nine edentate jaws (19 maxillae, 10 mandibles) treated with 165 implants using the Teeth-in-an-Hour™ protocol were included. In these patients, peri-implant soft tissue conditions and radiographic marginal bone changes were evaluated after ≥1 year of functional loading (mean: 19 months). RESULTS The mean probing depth at case level was 2.6 mm (SD: 0.6). Bleeding on probing was recorded as a mean of 81.9% (SD: 23.0). Plaque index showed a wide range of 0-100%. The mean marginal bone change of measured sites evaluated on intraoral radiographs was -1.2 mm (SD: 1.4). A marginal bone loss more than 1.5 mm or 2.0 mm was observed in 42% and 27% of the measured sites, respectively. A pressure-like-ulcer was found in 9 cases. Implants with marginal bone loss of >1.5 mm were more frequently observed in cases with an ulcer than cases where no ulcer was found. CONCLUSION Although the mean marginal bone loss after function in the present study was within the range of other reports presenting mean bone loss data after immediate implant loading, our patients showed a wide range of bone loss with several sites, where the bone loss was greater than the commonly used successful level (>1.5 mm).

Complex systematic review ‐ Perioperative antibiotics in conjunction with dental implant placement

OBJECTIVES The aim of this study was to revisit the available scientific literature regarding perioperative antibiotics in conjunction with implant placement by combining the recommended methods for systematic reviews and complex systematic reviews. MATERIAL AND METHODS A search of Medline (OVID), The Cochrane Library (Wiley), EMBASE, PubMed and Health technology assessment (HTA) organizations was performed, in addition to a complementary hand-search. Selected systematic reviews and primary studies were assessed using GRADE and AMSTAR, respectively. A meta-analysis was performed. RESULTS The literature search identified 846 papers of which 10 primary studies and seven systematic reviews were included. Quality assessment of the systematic reviews revealed two studies of moderate risk of bias and five with high risk of bias. The two systematic reviews of moderate risk of bias stated divergent numbers needed to treat (NNT) to prevent one patient from implant failure. Four of the primary studies comparing antibiotic prophylaxis with placebo were estimated to be of low, or moderate, risk of bias and subjected to meta-analysis. The NNT was 50 (pooled RR 0.39, 95% CI 0.18, 0.84; P = 0.02). None of these four studies individually show a statistical significant benefit of antibiotic prophylaxis. Furthermore, narrative analysis of the studies eligible for meta-analysis reveals clinical heterogeneity regarding intervention and smoking. CONCLUSION Antibiotic prophylaxis in conjunction with implant placement reduced the risk for implant loss by 2%. However, the sub-analysis of the primary studies suggests that there is no benefit of antibiotic prophylaxis in uncomplicated implant surgery in healthy patient.

The patient undergoing implant therapy. Summary and consensus statements. The 4th EAO Consensus Conference 2015

INTRODUCTION The assignment for this working group was to update the existing knowledge regarding factors considered being of special relevance for the patient undergoing implant therapy. This included areas where conflicting opinions exists since long or recently has been expressed, like the role of antibiotic prophylaxis in dental implant surgery and peri-implantitis. Also areas with growing interest and concern such as patient-reported outcome measures (PROMs) and health-economy was included in this review. MATERIALS AND METHODS The literature in the respective areas of interest (antibiotic prophylaxis, peri-implantitis, patient-reported outcome measurements and health-economic aspects) was searched using different strategies for the different papers. Search strategies ranged from a complex systematic review to systematic- and narrative reviews, depending on subject and available literature. All collected material was critically reviewed. Four manuscripts were subsequently presented for group analysis and discussion and plenum discussions and concensus approval. The selected areas were considered to be of key importance and relevance for the patient undergoing implant therapy. RESULTS The results and conclusions of the review process are presented in the respective papers. The groups conclusions, identified knowledge gaps, directions for future research and concensus statements are presented in this article. The following reviews were available for group discussions and the foundation for subsequent plenary sessions: Lund B, Hultin M, Tranaeus S, Naimi-Akbar A, Klinge B. (2015) Perioperative antibiotics in conjunction with dental implant placement. A complex systematic review. Renvert S & Quirynen M. (2015) Risk indicators for peri-implantitis. A narrative review. De Bruyn H, Raes S, Matthys C, Cosyn J. (2015) The current use of patient centered/reported outcomes in implant dentistry. A systematic review. Beikler T & Flemmig T.F. (2015) Economic evaluation of implant-supported prostheses. A narrative review.

Developing implant dentistry education in Europe: the continuum from undergraduate to postgraduate education and continuing professional development.

INTRODUCTION Implant dentistry is a treatment modality which has mainstream clinical practice of comprehensive care, which however is not adequately represented in the undergraduate dental curricula. A consensus workshop organised by ADEE in 2008, set the benchmarks for the knowledge and competences a modern dental practitioner must possess with regard to implant dentistry, as well as defined undergraduate and postgraduate pathways for the acquisition of these competences. Today, 5 years later, there exist several challenges for the implementation of these benchmarks in both undergraduate curricula but also post-graduation educational pathways. METHODS A consensus workshop was organised by ADEE, bringing together 48 opinion leaders, including academic teachers of all disciplines related to implant dentistry, specialists, representatives of relevant scientific and professional associations, as well as industry delegates. The objectives of the workshop were to evaluate the existing scientific literature, reported experience and best practices in order to identify potential and limitations for the implementation of implant dentistry in the undergraduate curriculum, as well produce recommendations for the optimal educational structures for postgraduate programmes and continuing professional development. RESULTS The scientific committee conducted two European-wide questionnaire surveys to better document the current state of education in implant dentistry. Upon completion of the surveys, reviewers were appointed to produce three scientific review papers, identifying current achievements and future challenges. Finally, during the 3 days of the workshop, all the evidence was reviewed and the main conclusions and recommendations that were adopted by all participants are reported in the present Consensus Paper. CONCLUSIONS Implementation of implant dentistry in the undergraduate curriculum has improved significantly, but still lags behind the benchmarks set in 2008 and the diversity between institutions remains big. At the post-graduation level, there is currently a wide diversity of courses and pathways towards competences related to implant dentistry and there is at present a great need for quality assurance, as well as standardisation and transparency of the learning outcomes.

Reimbursement systems influence prosthodontic treatment of adult patients

Abstract Objective. To evaluate the influence of reimbursement system and organizational structure on oral rehabilitation of adult patients with tooth loss. Materials and methods. Patient data were retrieved from the databases of the Swedish Social Insurance Agency. The data consisted of treatment records of patients aged 19 years and above claiming reimbursement for dental care from July 1, 2007 until June 30, 2009. Before July 1, 2008, a proportionately higher level of subsidy was available for dental care in patients 65 years and above, but thereafter the system was changed, so that the subsidy was the same, regardless of the patient’s age. Prosthodontic treatment in patients 65 years and above was compared with that in younger patients before and after the change of the reimbursement system. Prosthodontic treatment carried out in the Public Dental Health Service and the private sector was also analyzed. Results. Data were retrieved for 722,842 adult patients, covering a total of 1,339,915 reimbursed treatment items. After the change of the reimbursement system, there was a decrease in the proportion of items in patients 65 years and above in relation to those under 65. Overall, there was a minimal change in the proportion of treatment items provided by the private sector compared to the public sector following the change of the reimbursement system. Conclusions. Irrespective of service provider, private or public, financial incentive such as the reimbursement system may influence the provision of prosthodontic treatment, in terms of volume of treatment.

Identifying patients in dental settings at risk of cardiovascular disease and diabetes

Background: The purpose of our study was to identify patients in a dental setting at risk of already having or developing high blood pressure or high plasma glucose, investigate possible associations between these conditions and periodontal status and explore the correlation between screening results and follow-up assessments concerning the need for medical treatment and/or lifestyle changes performed by medical staff.Methods: A total of 170 dental patients were consecutively included at their regular yearly check-up visit. Data on age, weight, height, amount and use of tobacco and medication for cardiovascular disease and diabetes mellitus were collected, as well as data about systolic and diastolic blood pressure, in addition to pulse and plasma glucose. Clinical and radiographic examinations revealed data about periodontal status by probing periodontal pockets and measuring marginal alveolar bone loss by means of x-rays. Patients who exceeded normal diastolic blood pressure and plasma glucose values were referred for diagnosis and care.Results: Thirty-nine patients exhibiting high values were provided referrals and 24 or 14.1% of the 170 participants required additional care. The correlation between oral and medical health care concerning blood pressure recorded was 64.5% (p<0.001), while the correlation was 40.0% (p<0.001) concerning plasma glucose. Among middle aged men and elderly subjects, the data revealed/showed a significant correlation between marginal alveolar bone loss and high systolic blood pressure (p=0.001).Conclusions: The correlation between oral health care and medical health care registrations based on blood pressure and plasma glucose indicates that it may be appropriate for dental professionals to perform opportunistic medical screening and refer risk patients to the medical care system before complications occur. In order to identify medical risk patients in dental settings on the basis of high blood pressure, a suggestion may be to examine middle-aged men and elderly patients of both sexes who exhibit radiographic markers for marginal alveolar bone loss.