Sivaraman Prakasam

Differential expression of TLR-2 and TLR-4 in the epithelial cells in oral lichen planus

OBJECTIVE Oral lichen planus (OLP) is a chronic inflammatory condition of the mucosa mediated by a complex signalling network between the keratinocytes and the sub-epithelial lymphocytes. Since OLP occurs in constantly renewing epithelium continuously exposed to commensals, we hypothesised that the epithelial cell microflora interactions may mediate the persistent inflammation. By virtue of their ability to respond to most oral commensal microorganisms, the toll like receptor-2 (TLR-2) and TLR-4 are the most widely investigated receptors in oral diseases. The overall objective of this study was to investigate the role of TLR-2 and TLR-4 in OLP. DESIGN Systemically healthy OLP and control subjects were recruited after obtaining the institutional review board approval. Expression of TLR-2 and TLR-4 proteins and transcripts in the tissue epithelium and in the epithelial cells isolated from saliva were determined by immunohistochemistry and quantitative real-time polymerase chain reaction respectively. RESULTS The tissue epithelium and the salivary epithelial cells expressed reduced TLR-2 and increased TLR-4 proteins and transcripts in OLP. The salivary epithelial cells from OLP subjects secreted elevated IL-12. However, upon stimulation with bacterial lipopolysaccharide the epithelial cells from OLP exhibited a mixed Th1 (IL-12) and Th2 (IL-4) response. Presence of dexamethasone significantly reduced inflammatory cytokines in the in vitro stimulated cultures of salivary epithelial cells from OLP subjects. CONCLUSION Collectively, our data support a critical role for the host-microbial interactions in the OLP pathogenesis. The potential use of exfoliated oral epithelial cells in saliva for functional analysis exponentially increases its value as biological specimen for clinical research.

Designing a safety checklist for dental implant placement: a Delphi study.

BACKGROUND Complications during and after dental implant placement can be a hindrance to successful treatment. Checklists are emerging as useful tools in error reduction in various fields. The authors selected a Delphi panel to explore the appropriate clinical practices involved in implant placement, with the objective of formulating a safety checklist that would aid in reducing errors. METHODS The authors administered a Delphi method survey to an expert panel of 24 board-certified periodontists to determine if consensus existed regarding the critical steps involved in implant placement. They defined consensus as 90 percent agreement among participants. Using the Delphi data, the authors designed a safety checklist for implant placement. RESULTS The panelists generated 20 consensus statements regarding essential steps in implant placement. The authors divided the statements into preoperative, intraoperative and postoperative phases. To determine the rationale for consensus decisions, the authors conducted a thematic qualitative analysis of responses to all open-ended questionnaire items, asking panel members how or why a particular procedure was performed. CONCLUSION The panelists reached a consensus regarding the steps they considered critical in implant placement. Further research is needed to assess the acceptance and effectiveness of this type of checklist in a clinical setting. Practical Implications. The authors developed a checklist that may be useful in reducing errors in placement of dental implants. If effective, this checklist ultimately will aid in minimizing risk and increasing implant success rates, especially for inexperienced practitioners, dental students, surgical residents and dental implant trainees (that is, dentists undergoing training to place implants through continuing education courses).

Prevalence and predictors of complications following facial reconstruction procedures

Facial reconstruction procedures are immensely challenging and are done for a multitude of reasons. The purpose of this report is to provide nationally representative estimates of different types of facial reconstructive procedures and to examine prevalence and predictors of a wide range of complications associated with these procedures in the USA. The Nationwide Inpatient Sample, the largest inpatient dataset for the USA, was used. Data for the years 2004-2010 related to facial reconstruction procedures were identified through ICD-9-CM procedure codes. Associated complications were identified using secondary diagnosis field codes. Multivariable logistic regression models were used to examine the association between patient/hospital-level factors and the occurrence of complications. A total 26,374 facial reconstruction procedures were performed. About 20% of all patients who had facial reconstruction procedures developed a complication. Frequently occurring complications included postoperative pneumonia (4.9% of hospitalizations), hemorrhage (3.9%), other infections (3.6%), non-healing wounds (3.5%), and iatrogenically induced complications (3.2%). Significant factors found to be consistently associated with different types of complications included age, co-morbid burden, sex, and type of admission. The reported results are generalizable within limitations and can be used by health care providers to tailor quality improvement initiatives to minimize or better treat complications in the high-risk cohorts.

A randomized split-mouth clinical trial on effectiveness of amnion-chorion membranes in alveolar ridge preservation: A clinical, radiologic, and morphometric study

PURPOSE Recent case reports suggest that amnion-chorion membranes (ACM) and dense polytetrafluoroethylene membranes (dPTFE) can be left exposed during ridge preservation. The aim of this study was to compare the effectiveness of these membranes in ridge preservation, particularly when they are intentionally left exposed. MATERIALS AND METHODS A split-mouth, single-blind, randomized trial design was used to compare treatments with the two membranes in 22 nonmolar sites on the same arch. Ridge dimensions were recorded clinically and with cone beam computed tomography prior to and 3 months after ridge preservation. Postoperative discomfort was recorded with Visual Analog Scale (VAS) forms. Mixed‑model analysis of variance was used to test significance. RESULTS Clinical and radiographic ridge dimensions were not significantly different between the two treatments. ACM sites had significantly more osteoid and higher bone volume density but significantly less graft particles and bone surface density compared with dPTFE. Mineralized bone area and soft tissue area were not significantly different between the two treatments. ACM sites had significantly lower postoperative VAS scores compared with dPTFE. CONCLUSION Intentionally exposed ACM is equally effective in ridge preservation compared with dPTFE. Additionally, ACM use may aid in reducing postoperative VAS scores, and potentially result in better quality of bone available for implant placement, as evidenced by improved histomorphometric measures.

A Risk of Bias Assessment of Randomized Controlled Trials (RCTs) on Periodontal Regeneration Published in 2013

OBJECTIVE The objective of this assessment is to evaluate the degree of risk of bias in randomized controlled trials published in 2013 and focusing on periodontal regeneration. METHODS Three reviewers searched and selected the trials based on pre-defined inclusion criteria. Predictor variables [number of authors, primary objective of the study, biomaterial employed, follow-up time periods, split mouth study (yes/no), journal, year of publication, country, scale (single/multi-center) and nature of funding] were extracted and risk of bias assessment using Cochrane risk of bias tool were performed independently by the three reviewers. RESULTS Seventeen RCTs were included in this assessment. The risk of bias in RCTs published in 2013 with a focus in periodontal regeneration varied significantly with only in less than 30% of the included trials, the overall risk of bias was found to be low, while 41% of trials were designated to have a higher degree of bias. Specifically, when looking at the domains assessed, 70% of the included trials reported an accepted method of sequence generation, blinding (whenever possible), completeness of outcome data or avoided selective outcome reporting. Meanwhile, only 47% of the included trials reported some form of allocation concealment. CONCLUSION In this assessment, of the included 17 trials, slightly more than 40% of them had a high risk of bias, underscoring the importance of careful appraisal of trials before implementing the study interventions in clinical practice and the need for more detailed analyses.

Flap Design, Suturing, and Healing

Tissue management is an integral and essential component of implant care. With the evolution of implant dentistry, the functional osteointegration of the implant to the recipient site is no longer considered an adequate measure of a successful outcome of therapy. The restoration of health, function, comfort, and aesthetics are parameters to be considered in the outcome of care. This becomes particularly significant in the anterior maxillary area where the expectation is that reconstructions must be indistinguishable from natural teeth. Different materials and surgical and restorative techniques are continuously being developed and tested to achieve this objective. Surgical tissue management, including soft tissue management, incision design, and suturing, and knowledge of anticipated healing outcomes are essential for a successful aesthetic outcome. This chapter describes flap design, papilla reconstruction techniques, management of soft tissue toward enhancement of attached gingiva, suturing materials, types of needles, types of knots, suturing techniques, and the various phases of soft tissue healing. A well thought-out surgical plan of flap design at every stage of implant surgery is critical to preserve and/or enhance the aesthetics and health of anterior implant restorations. Knowledge of the factors that affect flap design, suturing techniques, and the principles of healing are paramount in obtaining an ideal aesthetic result of an implant restoration that is indistinguishable from adjacent natural dentition.

Impact of Periapical Abscess on Infectious Complications in Patients Undergoing Extracorporeal Circulation Auxiliary to Open-Heart Surgical Procedures

Objective Extracorporeal circulation auxiliary to open‐heart surgeries (ECAOHS) may exert nonphysiological stresses on periapical abscessed tissues leading to hematogenous spread of microbes. The aim of this report was to estimate risk of postoperative infectious complications in patients with periapical abscesses and undergoing ECAOHS. Methods A retrospective analysis of Nationwide Inpatient Sample (years 2009 and 2010) was conducted. All patients (aged 19 to 65 years) who underwent ECAOHS were selected. International Classification of Diseases‐9‐Clinical Modification codes were used to identify the presence of periapical abscess and infectious complications. Multivariable logistic regression models were used to examine the associations between the presence of periapical abscess and occurrence of infectious complications. Results A total of 265,235 patients underwent an ECAOH procedure. Of these, 431 patients had a periapical abscess. Septicemia developed in 16% of those with periapical abscess (compared with 4.2% in those without periapical abscess). Those with periapical abscess had higher rates of any of the infectious complications when compared with those without periapical abscess (30.2% vs 11.6%, respectively). After adjustment for multiple confounders, those with periapical abscess were associated with higher odds for developing septicemia (odds ratio = 2.51, 95% confidence interval = 1.06‐5.91, P = .04) and any of the infectious complications (odds ratio = 2.23, 95% confidence interval = 1.08‐4.59, P = .03) when compared with those who did not have periapical abscess. Conclusions Those with periapical abscess are associated with higher odds for infectious complications when compared with those without periapical abscess.

Original ContributionsCover StoryDesigning a safety checklist for dental implant placement: A Delphi study

BACKGROUND Complications during and after dental implant placement can be a hindrance to successful treatment. Checklists are emerging as useful tools in error reduction in various fields. The authors selected a Delphi panel to explore the appropriate clinical practices involved in implant placement, with the objective of formulating a safety checklist that would aid in reducing errors. METHODS The authors administered a Delphi method survey to an expert panel of 24 board-certified periodontists to determine if consensus existed regarding the critical steps involved in implant placement. They defined consensus as 90 percent agreement among participants. Using the Delphi data, the authors designed a safety checklist for implant placement. RESULTS The panelists generated 20 consensus statements regarding essential steps in implant placement. The authors divided the statements into preoperative, intraoperative and postoperative phases. To determine the rationale for consensus decisions, the authors conducted a thematic qualitative analysis of responses to all open-ended questionnaire items, asking panel members how or why a particular procedure was performed. CONCLUSION The panelists reached a consensus regarding the steps they considered critical in implant placement. Further research is needed to assess the acceptance and effectiveness of this type of checklist in a clinical setting. Practical Implications. The authors developed a checklist that may be useful in reducing errors in placement of dental implants. If effective, this checklist ultimately will aid in minimizing risk and increasing implant success rates, especially for inexperienced practitioners, dental students, surgical residents and dental implant trainees (that is, dentists undergoing training to place implants through continuing education courses).

Designing a safety checklist for dental implant placement

BACKGROUND Complications during and after dental implant placement can be a hindrance to successful treatment. Checklists are emerging as useful tools in error reduction in various fields. The authors selected a Delphi panel to explore the appropriate clinical practices involved in implant placement, with the objective of formulating a safety checklist that would aid in reducing errors. METHODS The authors administered a Delphi method survey to an expert panel of 24 board-certified periodontists to determine if consensus existed regarding the critical steps involved in implant placement. They defined consensus as 90 percent agreement among participants. Using the Delphi data, the authors designed a safety checklist for implant placement. RESULTS The panelists generated 20 consensus statements regarding essential steps in implant placement. The authors divided the statements into preoperative, intraoperative and postoperative phases. To determine the rationale for consensus decisions, the authors conducted a thematic qualitative analysis of responses to all open-ended questionnaire items, asking panel members how or why a particular procedure was performed. CONCLUSION The panelists reached a consensus regarding the steps they considered critical in implant placement. Further research is needed to assess the acceptance and effectiveness of this type of checklist in a clinical setting. Practical Implications. The authors developed a checklist that may be useful in reducing errors in placement of dental implants. If effective, this checklist ultimately will aid in minimizing risk and increasing implant success rates, especially for inexperienced practitioners, dental students, surgical residents and dental implant trainees (that is, dentists undergoing training to place implants through continuing education courses).

Cover story: Designing a safety checklist for dental implant placement: A Delphi study

BACKGROUND Complications during and after dental implant placement can be a hindrance to successful treatment. Checklists are emerging as useful tools in error reduction in various fields. The authors selected a Delphi panel to explore the appropriate clinical practices involved in implant placement, with the objective of formulating a safety checklist that would aid in reducing errors. METHODS The authors administered a Delphi method survey to an expert panel of 24 board-certified periodontists to determine if consensus existed regarding the critical steps involved in implant placement. They defined consensus as 90 percent agreement among participants. Using the Delphi data, the authors designed a safety checklist for implant placement. RESULTS The panelists generated 20 consensus statements regarding essential steps in implant placement. The authors divided the statements into preoperative, intraoperative and postoperative phases. To determine the rationale for consensus decisions, the authors conducted a thematic qualitative analysis of responses to all open-ended questionnaire items, asking panel members how or why a particular procedure was performed. CONCLUSION The panelists reached a consensus regarding the steps they considered critical in implant placement. Further research is needed to assess the acceptance and effectiveness of this type of checklist in a clinical setting. Practical Implications. The authors developed a checklist that may be useful in reducing errors in placement of dental implants. If effective, this checklist ultimately will aid in minimizing risk and increasing implant success rates, especially for inexperienced practitioners, dental students, surgical residents and dental implant trainees (that is, dentists undergoing training to place implants through continuing education courses).