Mario Berengo

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.

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.

Extraoral endodontic treatment, odontotomy and intentional replantation of a double maxillary lateral permanent incisor: case report and 6‐year follow‐up

AIM To describe combined endodontic, surgical and orthodontic treatment of a maxillary lateral incisor fused with a supernumerary. SUMMARY Double tooth is a dental irregularity consequent to fusion of two or more teeth or dental gemination. The teeth most commonly involved are deciduous, but in 0.1% of cases permanent teeth are affected, in which case aesthetic, functional and periodontal problems can result. This paper reports a clinical case of a double tooth in the position of the maxillary right lateral permanent incisor. Combined orthodontic, endodontic and surgical treatment (intentional replantation) allowed the tooth to be retained without periodontal compromise and with a positive orthodontic result both immediately and 6 years following intervention. *A conservative approach that addresses periodontal, pulpal and tooth tissues, can result in the retention of a double tooth. *Maintenance of the root and alveolar bone in young adults at least until full skeletal maturation should be the main treatment objective.

A Hyaluronan-Based Scaffold for the in Vitro Construction of Dental Pulp-Like Tissue

Dental pulp tissue supports the vitality of the tooth, but it is particularly vulnerable to external insults, such as mechanical trauma, chemical irritation or microbial invasion, which can lead to tissue necrosis. In the present work, we present an endodontic regeneration method based on the use of a tridimensional (3D) hyaluronan scaffold and human dental pulp stem cells (DPSCs) to produce a functional dental pulp-like tissue in vitro. An enriched population of DPSCs was seeded onto hyaluronan-based non-woven meshes in the presence of differentiation factors to induce the commitment of stem cells to neuronal, glial, endothelial and osteogenic phenotypes. In vitro experiments, among which were gene expression profiling and immunofluorescence (IF) staining, proved the commitment of DPSCs to the main components of dental pulp tissue. In particular, the hyaluronan-DPSCs construct showed a dental pulp-like morphology consisting of several specialized cells growing inside the hyaluronan fibers. Furthermore, these constructs were implanted into rat calvarial critical-size defects. Histological analyses and gene expression profiling performed on hyaluronan-DPSCs grafts showed the regeneration of osteodentin-like tissue. Altogether, these data suggest the regenerative potential of the hyaluronan-DPSC engineered tissue.

Splinted and Unsplinted Short Implants in Mandibles: A Retrospective Evaluation With 5 to 16 Years of Follow-Up

BACKGROUND The aim of this retrospective study is to investigate the medium- to long-term prognosis of short implants in partially and totally edentulous patients with mandibular bone atrophy. METHODS The study involved 109 patients with 280 implants placed in the mandible. The implants were 7 or 8.5 mm long and 3.75 or 4 mm in diameter. The implant surfaces were machined (M; n = 176) or rough (R; n = 104). Patients were asked to attend a radiographic and clinical follow-up, and their previous clinical records and radiographs were assessed. Implant-related and prosthetic failures and complications were recorded. RESULTS The mean follow-up was 9 years (range of 5 to 16 years). The survival rate (SSR) and success rate (SR) were calculated using life-table analysis for both M and R short implants. The M implants had a 16-year SSR of 95.7% and a corresponding SR of 93.9%, whereas the 16-year SSR and SR for the R implants were 97.2% and 95.2%, respectively. The mean ± SD bone resorption for all implants was 1.37 ± 0.5 mm. For marginal bone loss, there was no statistically significant difference between the two implant lengths (P = 0.38) or diameters (P = 0.34) or between the M and R implant surfaces (P = 0.47). CONCLUSIONS Different implant lengths, diameters, and surface treatments do not appear to influence the prognosis of the implant. Within the limitation that most of the short implants were splinted to longer implants, the reduced length of the fixtures did not worsen the long-term survival of the implant-supported fixed prostheses.

Destructive Membranous Periodontal Disease (Ligneous Gingivitis): A Literature Review

BACKGROUND Destructive membranous periodontal disease, or ligneous gingivitis, is a rare condition involving nodular gingival enlargement with ulceration and periodontal tissue destruction. This review gives a brief account of the cases reported in the literature. An effort is also made to define the periodontal disease caused by plasminogen deficiency with a view to its potential inclusion in the classification of periodontal diseases. METHODS A MEDLINE/PubMed and manual search was conducted to find papers describing ≥1 case of ligneous disease involving the oral mucosa. RESULTS We identified 23 articles reporting 35 cases. For each patient, we analyzed various characteristics, including age, sex, age of onset, oral symptoms, histologic features, plasminogen levels (functional activity, plasma antigen), genetic features, treatment, and results of treatment during the reported follow-up. CONCLUSIONS Ligneous gingivitis is a rare periodontal disorder closely associated with ligneous conjunctivitis and plasminogen deficiency. Its diagnosis may be supported by the finding of genetic mutations responsible for the condition. Research is focusing on the future development of an effective therapy capable of arresting the destructive evolution of the disease. Additional studies, investigating features such as probing depth and attachment loss, are needed for the appropriate classification of this periodontal disease.

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.

Managing dentoalveolar surgical procedures in patients taking new oral anticoagulants.

The development of new orally administered anticoagulants, such as dabigatran, rivaroxaban, and apixaban, in the past few years has focused on avoiding some of the drawbacks associated with warfarin. This work aims to illustrate the main features of the most commonly used new oral anticoagulants, reviewing the current literature on the management of patients taking these drugs and needing oral and implant surgery, and discussing the currently proposed related guidelines.

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®.

Assessing the need for computed tomography for lower-third-molar extraction: a survey among 322 dentists

PurposeOrthopantomograms (OPT) are used to assess the anatomical relationship between the inferior alveolar nerves (IAN) and the roots of third molars and the related risk of postextraction iatrogenic neurological lesions. When the risk is high, computed tomography (CT) or conebeam CT may be warranted. We investigated how dentists judged the need for CT from OPT to ascertain whether they comply with criteria of justification, appropriateness and optimisation in prescribing examinations involving radiation.Materials and methodsA total of 2,713 letters were sent to Italian dentists (Veneto region), inviting them to access an Internet Web site showing 20 OPTs and answer a questionnaire on the need for CT or periapical X-ray. The gold standards were CT images corresponding to the OPTs. The respondents’ answers were rated for appropriateness and their tendency to over- or underprescribe CT.ResultsThe questionnaire was completed by 11.9% of the dentists contacted. The response rate was compatible with a Web survey. Their answers generally came close to the gold standard, achieving a mean appropriateness rating of 0.636 (range 0–1). An overlap between the mandibular canal and the third-molar root was the anatomical relationship most often noted. Recommendations for CT were proportional to the number of radiographic signs indicating a risk of inferior alveolar nerve injury. Periapical X-ray was considered useful by 54.9% of dentists not recommending CT. The main reason stated for not recommending CT was that it was unnecessary for the purposes of the extraction.ConclusionsOur survey revealed a cautious approach among the professionals interviewed, who tended to overprescribe CT.RiassuntoObiettivoL’ortopantomografia (OPT) è utilizzata per valutare la vicinanza del nervo alveolare inferiore (NAI) alle radici del terzo molare e il rischio di una lesione neurologica iatrogena post-estrattiva. Quando il rischio è elevato, può essere richiesta la tomografia computerizzata (TC) o TC cone beam. Lo scopo del nostro lavoro è di verificare come viene percepita la necessità di TC dopo visione di OPT da parte di un campione di dentisti, ovvero se vi è rispetto dei criteri di giustificazione, appropriatezza e ottimizzazione nella prescrizione di esami radiologici.Materiali e metodiSono state inviate 2713 lettere a dentisti italiani (regione Veneto), chiedendo di accedere ad un sito internet contenente 20 OPT ed un questionario riguardanti l’indicazione alla TC o alla radiografia endorale. Come gold standard si sono utilizzate le TC corrispondenti alle OPT. Le risposte degli intervistati sono state valutate per correttezza e tendenza a prescrivere o non prescrivere la TC.RisultatiHa risposto l’11,9% della popolazione oggetto d’indagine. Il tasso di risposta è compatibile con un sondaggio web. I rispondenti si sono avvicinati al gold standard e l’indice di correttezza totale è stato pari a 0,636 (range di 0–1). La sovrapposizione del canale mandibolare e della radice è la relazione più rilevata. La richiesta di TC è proporzionale al numero di segni rilevati. Il 54,9% di chi non prescrive la TC ritiene utile una radiografia periapicale. Il motivo principale per cui non viene prescritta la TC è per la mancanza di necessità ai fini dell’estrazione.ConclusioniIl nostro studio ha rivelato una certa cautela dei professionisti che tendono a sovra-prescrivere la TC.