Systemic antibiotics and the risk of superinfection in peri-implantitis

Systemic antibiotics in the surgical treatment of peri-implantitis: A randomized placebo-controlled trial

AIM

To study the clinical, radiographic and microbiological outcomes after surgical treatment of peri-implantitis, with or without adjunctive systemic antibiotics.

MATERIALS AND METHODS

Eighty-four patients (113 implants) with peri-implantitis were randomized into three groups (A, amoxicillin and metronidazole; B, phenoxymethylpenicillin and metronidazole; or C, placebo). Treatment included resective surgery and implant surface decontamination with adjunctive antibiotics or placebo. Primary outcomes were probing pocket depth (PPD) reduction and marginal bone level (MBL) stability. Secondary outcomes were treatment success (defined as PPD ≤ 5 mm, bleeding on probing [BOP] ≤ 1site, absence of suppuration on probing [SOP] and absence of progressive bone loss of >0.5 mm), changes in BOP/SOP, mucosal recession (REC), clinical attachment level (CAL), bacterial levels and adverse events. Outcomes were evaluated for up to 12 months. The impact of potential prognostic indicators on treatment success was evaluated using multilevel logistic regression analysis.

RESULTS

A total of 76 patients (104 implants) completed the study. All groups showed clinical and radiological improvements over time. Statistically significant differences were observed between groups for MBL stability (A = 97%, B = 89%, C = 76%), treatment success (A = 68%, B = 66%, C = 28%) and bacterial levels of Aggregatibacter actinomycetemcomitans and Tannerella forsythia, favouring antibiotics compared to placebo. Multiple regression identified antibiotic use as potential prognostic indicator for treatment success. Gastrointestinal disorders were the most reported adverse events in the antibiotic groups.

CONCLUSIONS

Adjunctive systemic antibiotics resulted in additional improvements in MBL stability. However, the potential clinical benefits of antibiotics need to be carefully balanced against the risk of adverse events and possible antibiotic resistance.

The Integration of Advanced Drug Delivery Systems into Conventional Adjuvant Therapies for Peri-Implantitis Treatment

Despite the high success rates of dental implants, peri-implantitis is currently the most common complication in dental implantology. Peri-implantitis has an inflammatory nature, it is associated with the accumulation of plaque in the peri-implant tissues, and its evolution can be progressive depending on various factors, comorbidities, and poor oral health. Prophylaxis and different treatment methods have been widely discussed in recent decades, and surgical and non-surgical techniques present both advantages and disadvantages. In this work, a literature review of different studies on the application of adjuvant treatments, such as local and systemic antibiotics and antiseptic treatments, was conducted. Positive outcomes have been found in the short (up to one year after treatment) and long term (up to ten years after treatment) with combined therapies. However, there is still a need to explore new therapies based on the use of advanced drug delivery systems for the effective treatment of peri-implantitis in the long term and without relapses. Hence, micro- and nanoparticles, implants, and injectable hydrogels, among others, should be considered in future peri-implantitis treatment with the aim of enhancing overall therapy outcomes.

The efficacy of bone reconstructive therapies in the management of peri-implantitis. A systematic review and meta-analysis

AIM

To evaluate the efficacy of bone reconstructive procedures for the reduction of probing pocket depth (PPD), bleeding on probing (BOP), and suppuration in peri-implantitis-related bone defects at ≥12-month follow-up.

MATERIALS AND METHODS

Three databases were searched for randomized controlled trials (RCTs) and controlled clinical trials (CCTs) that compared bone reconstructive therapies to access flap surgery (AFS) (Focused Question-FQ 1), and RCTs, CCTs, and prospective case series that assessed the efficacy of reconstructive therapies (FQ 2). Meta-analysis was performed for FQ1 when more than three studies were identified, while for FQ2 a network was drawn based on RCTs with common treatment arms.

RESULTS

Seven RCTs were identified for FQ1 while five RCTs and six prospective case series for FQ2. There was no significant difference in PPD change between AFS and reconstructive surgery (-0.387; p = .325) at 12 months. Furthermore, no clear differences in terms of PPD and BOP changes resulted from the different reconstructive therapies included in the network. Only a small percentage of treated cases with any modality achieved peri-implantitis resolution, as defined by different composite outcomes.

CONCLUSIONS

Reconstructive surgery does not offer significant improvements in peri-implant clinical parameters as compared to AFS at 12 months. It was not possible to establish a hierarchy of efficacy among the different biomaterials employed for reconstructive surgery.

Antibiotics as Adjunctive Therapy in the Non-Surgical Treatment of Peri-Implantitis: A Systematic Review and Meta-Analysis

The role of antibiotics as adjunctive therapy in the non-surgical treatment of peri-implantitis is uncertain. The aim of this systematic review of randomized controlled trials was to assess the efficacy of antibiotic therapy, local or systemic, as an adjunctive to the non-surgical therapy of peri-implantitis. Primary outcomes were: implant success rate and complications, changes in radiographic bone level, probing pocket depth (PPD), probing attachment level (PAL), bleeding on probing (BOP) and peri-implantitis resolution. Six studies were included: two using topical and four systemic antibiotics. Adjunctive local antibiotics improved PPD (mean difference (MD) = 0.6 mm; 95% CI 0.42-0.78), BOP (MD = 0.15% (95% CI 0.10, 0.19)) and the success rate (risk ratio = 9.89; 95% CI 2.39-40.84). No significant difference in bone level and success rate were found with the use of systemic antibiotics, although they appeared to improve PPD (MD = 1.15 mm; 95% CI 0.31-1.99) and PAL (MD = 1.10 mm; 95% CI 0.13-2.08). Within the limitations of this review, the adjunctive local antibiotics showed improved outcomes in terms of success rate, PPD and BOP, while adjunctive systemic antibiotics improved PPD and PAL only. Peri-implantitis resolution was about 20-30% using adjunctive local antibiotics, whilst it ranged from 2% to 65% with adjunctive systemic antibiotics. Findings are still controversial, since they are based on few studies with high heterogeneity, at the uncertain or high risk of bias and involve few patients. Non-surgical debridement and maintenance periodontal support therapy remain pivotal and the adjunctive use of antibiotics for peri-implantitis cannot be routinely recommended, even considering the increasing concern on antibiotic resistance.

Antimicrobial-free graphene nanocoating decreases fungal yeast-to-hyphal switching and maturation of cross-kingdom biofilms containing clinical and antibiotic-resistant bacteria

Candida albicans and methicillin-resistant Staphylococcus aureus (MRSA) synergize in cross-kingdom biofilms to increase the risk of mortality and morbidity due to high resistance to immune and antimicrobial defenses. Biomedical devices and implants made with titanium are vulnerable to infections that may demand their surgical removal from the infected sites. Graphene nanocoating (GN) has promising anti-adhesive properties against C. albicans. Thus, we hypothesized that GN could prevent fungal yeast-to-hyphal switching and the development of cross-kingdom biofilms. Herein, titanium (Control) was coated with high-quality GN (coverage > 99%). Thereafter, mixed-species biofilms (C. albicans combined with S. aureus or MRSA) were allowed to develop on GN and Control. There were significant reductions in the number of viable cells, metabolic activity, and biofilm biomass on GN compared with the Control (CFU counting, XTT reduction, and crystal violet assays). Also, biofilms on GN were sparse and fragmented, whereas the Control presented several bacterial cells co-aggregating with intertwined hyphal elements (confocal and scanning electronic microscopy). Finally, GN did not induce hemolysis, an essential characteristic for blood-contacting biomaterials and devices. Thus, GN significantly inhibited the formation and maturation of deadly cross-kingdom biofilms, which can be advantageous to avoid infection and surgical removal of infected devices.

Efficacy of Er:YAG laser for the peri-implantitis treatment and microbiological changes: a randomized controlled trial

The aims of this study were to identify the microbiological changes in the periodontal pockets following an Er:YAG laser (ERL) irradiation and mechanical debridement to compare the effectiveness of ERL irradiation to mechanical debridement for peri-implantitis treatment through randomized controlled trials. Twenty-three patients with peri-implantitis lesions were treated in either a test group, ERL set at energy level of 100 mJ/pulse, frequency of 10 Hz, pulse duration was 100 µs, and irradiated by three passages, or a control group, with mechanical debridement using an ultrasonic scaler. An examiner measured the following clinical parameters at different stages (a baseline and at 3- and 6-month post-treatment): probing depth (PD), bleeding on probing (BOP), marginal bone loss (MBL), and anaerobic bacteria counts. Linear regression, with generalized estimation equations, was used to compare the clinical parameters and anaerobic bacterial counts at different stages and between groups. The anaerobic bacterial counts significantly decreased within the control group during the follow-ups. At the 6-month follow-up, both groups showed a significant reduction in PD (test group: mean difference of 0.84 mm; control group: mean difference of 0.41 mm), and the test group showed a significantly higher PD reduction on the buccal site (1.31 mm) compared to that of the control group (0.25 mm). Both ERL and mechanical debridement treatments led to significant improvements in PD. When mechanical debridement therapy was used, significant anaerobic bacterial count reductions were observed. Future treatment of peri-implantitis should involve a combination of both of these therapies.

Flagellotropic Bacteriophages: Opportunities and Challenges for Antimicrobial Applications

Bacteriophages (phages) are the most abundant biological entities in the biosphere. As viruses that solely infect bacteria, phages have myriad healthcare and agricultural applications including phage therapy and antibacterial treatments in the foodservice industry. Phage therapy has been explored since the turn of the twentieth century but was no longer prioritized following the invention of antibiotics. As we approach a post-antibiotic society, phage therapy research has experienced a significant resurgence for the use of phages against antibiotic-resistant bacteria, a growing concern in modern medicine. Phages are extraordinarily diverse, as are their host receptor targets. Flagellotropic (flagellum-dependent) phages begin their infection cycle by attaching to the flagellum of their motile host, although the later stages of the infection process of most of these phages remain elusive. Flagella are helical appendages required for swimming and swarming motility and are also of great importance for virulence in many pathogenic bacteria of clinical relevance. Not only is bacterial motility itself frequently important for virulence, as it allows pathogenic bacteria to move toward their host and find nutrients more effectively, but flagella can also serve additional functions including mediating bacterial adhesion to surfaces. Flagella are also a potent antigen recognized by the human immune system. Phages utilizing the flagellum for infections are of particular interest due to the unique evolutionary tradeoff they force upon their hosts: by downregulating or abolishing motility to escape infection by a flagellotropic phage, a pathogenic bacterium would also likely attenuate its virulence. This factor may lead to flagellotropic phages becoming especially potent antibacterial agents. This review outlines past, present, and future research of flagellotropic phages, including their molecular mechanisms of infection and potential future applications.

A Systematic Review and Meta-Analysis of Systemic Antibiotic Therapy in the Treatment of Peri-Implantitis

Research has been conducted into the advantages of the systemic administration of antibiotics. The aim of this systematic review and meta-analysis was to assess the efficacy of systemic antibiotic administration in the treatment of peri-implantitis in terms of bleeding on probing (BoP) and probing pocket depth (PPD). Literature searches were performed across PubMed, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL) to identify randomized controlled trials and observational clinical studies. After peri-implantitis treatment, PPD was reduced by 0.1 mm (p = 0.58; IC 95% [-0.24, 0.47]), indicating a non-significant effect of antibiotic administration on PPD. The BoP odds ratio value was 1.15 (p = 0.5; IC 95% [0.75, 1.75]), indicating that the likelihood of bleeding is almost similar between the test and control groups. Secondary outcomes were found, such as reduced clinical attachment level, lower suppuration and recession, less bone loss, and a reduction in total bacterial counts. In the treatment of peri-implantitis, the systemic antibiotic application reduces neither PPD nor BoP. Therefore, the systemic administration of antibiotics, in the case of peri-implantitis, should be rethought in light of the present results, contributing to address the problem of increasing antibiotic resistance.

Dental Implant Healing Screws as Temporary Oral Drug Delivery Systems for Decrease of Infections in the Area of the Head and Neck

Background

Periimplantitis is continuously one of major threats for the uneventful functioning of dental implants. Current approaches of drug delivery systems are being more commonly implemented into oral- and maxillofacial biomaterials in order to decrease the risk of implant failure due to bacterial infection. Silver nanoparticles and their compounds have been proven in eradicating oral bacteria responsible for peri-implant infections. Nevertheless, their evaluation as coating for implant abutments has not been extensively evaluated so far. This article describes a novel coating consisting of zinc oxide (ZnO) and silver (Ag) nanoparticles (NPs). This coating was used to modify healing abutments that could be used as drug delivery systems in oral implantology.

Materials and Method

Nanoparticles with a ZnO + 0.1% Ag composition were produced by microwave solvothermal synthesis and then incorporated into the surface of titanium healing abutments by high-power ultrasonic deposition. Surface morphology, roughness, wettability were evaluated. Ability of biofilm formation inhibition was tested against S. mutans, S. oralis, S. aureus and E. coli.

Results

ZnO+0.1%Ag NPs were sufficiently deposed on the surface of the abutments creating nanostructured coating which increased surface roughness and decreased wettability. Modified abutments significantly decreased bacterial biofilm formation. Bacteria present in SEM studies were unlikely to settle and replicate on the experimental abutments as their cells were rounded, insufficiently spread on the surface and covered with released NPs.

Conclusion

Experimental nanostructured abutments were easily manufactured by high-power ultrasonic deposition and provided significant antibacterial properties. Such biomaterials could be used as temporary drug delivery abutments for prevention and treatment of intra- and extraoral peri-implant infections in the area of the head and neck.

The efficacy of systemic antibiotics as an adjunct to surgical treatment of peri-implantitis: a systematic review

BACKGROUND

Microbial biofilm accumulation is the main cause of peri-implantitis. The majority of surgical peri-implantitis treatment protocols suggests adjunctive use of systemic antibiotics to target specific putative bacteria. The aim of this systematic review was to critically evaluate the adjunctive use of systemically administered antibiotics in surgical treatment of peri-implantitis by reviewing previously published systematic reviews and primary studies.

METHODS

A systematic literature search was conducted in four electronic databases (MEDLINE, The Cochrane Library, EMBASE, and Web of Science) for randomised controlled trials, cohort studies, case-control studies, and systematic reviews reporting surgical treatment of peri-implantitis with and without adjunctive systemically administered antibiotic therapy. The included systematic reviews and primary studies were qualitatively assessed using AMSTAR and GRADE, respectively. No restrictions were set for date of publication, journal, or language.

RESULTS

The literature search identified 681 papers. Only seven systematic reviews and two primary studies met the inclusion criteria. Four out of seven included systematic reviews concluded that no evidence exists for use of systemic antibiotics to improve the clinical outcomes in surgical treatment of peri-implantitis. One review did not estimate the level of evidence, one did not clearly state any beneficial effect, whereas one reported a limited adjunctive effect. Further, the two included primary studies did not show a long-term significant benefit of adjunctive use of systemically administrated antibiotics. However, one study reported a short-term adjunctive effect in patients with modified surface implants. Due to heterogeneity in study design, low number of included primary studies, and grade of bias, no meta-analysis was performed.

CONCLUSION

The use of systemically administered antibiotics as an adjunct to surgical interventions of peri-implantitis cannot be justified as a part of a standard treatment protocol. A pervasive problem is the lack of uniform diagnosis criteria for peri-implantitis, deficient information about patient characteristics, absence of high quality long-term randomised controlled trials, and authors' declaration on conflict of interest.

Assessment of Disinfection Potential of Q-Switch Nd: YAG Laser on Contaminated Titanium Implant Surfaces

Peri-implantitis (PI) is a relatively frequent pathology that compromises the overall survival of the dental implant. Adjunctive approaches for the conventional mechanical debridement are being suggested to optimize the treatment of PI. The goal of the study was the assessment of the disinfection potential of the Q-Switch Nd: YAG laser on contaminated titanium implant surfaces. A total of 72 sterile titanium discs were used and divided into three groups: 24 contaminated titanium discs treated with the laser (study Group L), 24 contaminated titanium discs with no treatment (control 1—Group C), and 24 sterile titanium discs with no treatment (control 2—Group S). Multi-species biofilm was used: Porphyromonas gingivalis, Fusobacterium nucleatum, Aggregatibacter actinomycetemcomitans, Streptococcus mutans, Streptococcus sobrinus, and Prevotella intermedia. Commensal bacteria were included also: Actinomyces naeslundii, Actinomyces viscosus, Streptococcus cristatus, Streptococcus gordonii, Streptococcus mitis, Streptococcus oralis, Streptococcus sanguinis, Streptococcus parasanguinis, and Veillonella parvula. Parameters delivered per pulse on the targeted surfaces of the titanium discs were an energy density of 0.597 J/cm² each pulse, a pulse power of 270 mW, a laser beam spot of 2.4 mm in diameter, and a rate of repetition of 10 Hertz (Hz) for a pulse duration of 6 nanoseconds (ns). The mode was no contact, and a distance of 500 micrometers was used with a total time of irradiation equal to 2 s (s). The collection of microbiological samples was made for all groups; colony-forming units (CFU) were identified by two different practitioners, and the average of their examinations was considered for each sample. The average of the TBC (CFU/mL) was calculated for each group. Values were 0.000 CFU/mL, 4767 CFU/mL, and 0.000 CFU/mL for Group L, Group C, and Group S, respectively. Therefore, the suggested treatment protocol was able to provoke a total disinfection of the contaminated titanium surfaces. A statistical difference was only found between Group L vs. Group C and between Group S vs. Group C. The difference was not significant between Group S and Group L. In conclusion, the present study confirmed that the Q-Switch Nd: YAG laser under our specific conditions can provide a total disinfection of the contaminated titanium surfaces.

Systemic antibiotic therapy as an adjunct to non-surgical peri-implantitis treatment: A single-blind RCT

Aim

The aim of this single‐blind RCT was to evaluate the adjunctive clinical and microbiological effect of systemic amoxicillin (AMX) plus metronidazole (MTZ) to non‐surgical treatment of peri‐implantitis.

Material and methods

Patients (N = 62) with peri‐implantitis were randomly assigned to receive full‐mouth mechanical debridement and decontamination and use of chlorhexidine (control group) or combined with antibiotic therapy of AMX/MTZ (test group). Primary outcome was change in bleeding score from baseline (T₀) to 3‐month follow‐up (T₃). Secondary parameters were plaque, suppuration, PPD, CAL, bone level, microbiology, adverse events and need for additional surgery. Data were analysed with linear multiple regression analysis.

Results

57 patients with 122 implants completed 3‐month follow‐up. Both groups showed major clinical improvements at T₃ in both peri‐implant and periodontal parameters. However, no significant differences were observed between both groups for any of the primary or secondary parameters.

Conclusions

Systemic antibiotic therapy of AMX/MTZ does not improve clinical and microbiological outcomes of non‐surgical peri‐implantitis treatment and should not be routinely recommended. Although complete disease resolution may be difficult to achieve, meticulously performed full‐mouth non‐surgical treatment, achieving a high level of daily oral hygiene and healthy periodontal tissues, can significantly improve the starting position of the subsequent (surgical) peri‐implantitis treatment phase.

Enzymatic biofilm destabilisation to support mechanical cleansing of inserted dental implant surfaces: an in-vitro pilot study

Peri-implantitis is caused by microbial contamination and biofilm formation on the implant surface. To achieve re-osseointegration, the microbes must be completely removed from the surface. Adjunctive to mechanical cleaning, chemical treatment with enzymes or other substances could optimise the treatment outcome. Therefore, we investigated the efficacy of different enzymes, a surfactant, and a chelator in destabilising dental polymicrobial biofilm. The biofilm destabilising effect of the glycosidases α-amylase, dextranase, DispersinB^®, and lysozyme, as well as the proteinase subtilisin A, and the nuclease Benzonase^®, the chelator EDTA, and the surfactant cocamidopropyl betaine were investigated on biofilms, inoculated with plaque on rough titanium discs. The test and the control solutions were incubated for 15 min at 36 °C on biofilms, and loosened biofilm mass was removed by shear stress with a shaker. Fluorescence-stained biofilms were microscopically analysed. Acceptable cell tolerability concentrations of test substances were determined by the MTT (tetrazolium dye) assay on the MG-63 cell line. A statistically significant biofilm destabilising effect of 10% was shown with lysozyme (2500 µg/ml).

Combination effect of laser diode for photodynamic therapy with doxycycline on a wistar rat model of periodontitis

Background

Periodontitis is a chronic inflammatory disease characterized by progressive damage on the structure of tooth-supporting tissues. The aim of the study is determining the combination photodynamic effect of diode laser 405 nm treatments and the administration of doxycycline 0.1% within 1, 3, 5, and 7 days on a Wistar rat model of periodontitis.

Methods

Samples were induced with Porphyromonas gingivalis ATCC33277 to allow periodontitis development and were treated with combination of doxycycline and laser diode, then statistical analysis was carried out (One-Way ANOVA test and the post-hoc Duncan test; Kruskal–Wallis test and Mann–Whitney follow-up test for non-parametric data). Samples were divided into five groups, laser exposure used was 405-nm diode laser with energy density of 8 J/cm². The expression level of histomorphometric was calculated by measuring the number of macrophages, lymphocytes, fibroblasts and the distance between the CEJ-AV.

Results

The results showed that the combination treatment of doxycycline and laser exposure yielded immunomodulatory effects. The expression level of fibroblast and the distance between CEJ-AV bone showed that the combination of doxycycline and laser therapy exerted healing effect in rat models of periodontitis on day 5 and 7.

Conclusion

The combination of doxycycline 0.1% and diode laser therapy provides a healing effect in rats models of periodontitis.

Peri-Implant Diseases: Diagnosis, Clinical, Histological, Microbiological Characteristics and Treatment Strategies. A Narrative Review

Since the use of dental implants is continuously increasing, it is imperative for dental practitioners to understand the nature and treatment of peri-implant diseases. The purpose of this manuscript is to comprehensively review peri-implant diseases, their characteristics, as well as their non-surgical and surgical treatment. To that end, the current literature was searched and a narrative review was conducted. It is essential that the case definitions described in the 2017 World Workshop on the Classification of Periodontal and Peri-implant Diseases and Conditions are used to diagnose and classify peri-implant health, peri-implant mucositis and peri-implantitis. While recent epidemiologic studies on peri-implant diseases exist, there is great heterogeneity in the definition of these conditions. Several risk factors and indicators are reported in the literature, with smoking and diabetes being the most universally accepted. In peri-implant mucositis, non-surgical treatment seems to be sufficient. However, for the treatment of peri-implantitis, a surgical approach, which includes open-flap debridement, apically positioned flap and guided bone regeneration, is considered more appropriate. A great variety of adjuncts to mechanical treatment have been reported with controversial results. Finally, studies comparing results from different peri-implantitis treatments are warranted in randomized controlled clinical trials in order to provide stronger evidence-based approaches.

A Narrative Review of Antimicrobial Stewardship Interventions within In-patient Settings and Resultant Patient Outcomes

The overuse of antibiotics has led to various healthcare problems such as the emergence of resistance in infectious microbes and mortality due to antibiotic resistant healthcare associated infections (HAIs). An antimicrobial stewardship (AMS) program is the set of interventions used worldwide to enhance the rational use of antibiotics especially for the hospitalized patients. This review aimed to describe the characteristics of the implemented AMS programs in various hospitals of the world mainly focusing on the interventions and patients outcomes. The literature about AMS program was searched through various databases such as PubMed, Google Scholar, Science Direct, Cochran Library, Ovid (Medline), Web of Science and Scopus. In this review the literature pertaining to the AMS programs for hospitalized patients is sorted on the basis of various interventions that are categorized as formulary restriction (pre-authorization), guideline development, clinical pathway development, educative interventions and prospective audit. Moreover a clear emphasis is laid on the patient outcomes obtained as a result of these interventions namely the infection control, drop in readmission rate, mortality control, resistance control and the control of an overall cost of antibiotic treatment obtained mainly by curbing the overuse of antibiotics within the hospital wards. AMS program is an efficient strategy of pharmacovigilance to rationalize the antimicrobial practice for hospitalized patients as it prevents the misuse of antibiotics, which ultimately retards the health threatening effects of various antibiotics.

Management of Peri-Implantitis Lesions without the Use of Systemic Antibiotics: A Systematic Review

BACKGROUND

This systematic review aims to assess the current evidence on the efficacy of surgical and non-surgical debridement techniques in the treatment of peri-implantitis lesions without the use of any antimicrobials.

METHOD

Five electronic databases (MEDLINE, Pubmed, Scopus, CINAHL and Cochrane) were used, alongside hand searches, to find relevant articles. Full-text articles that were randomised controlled trials, published in the English language from 2011 onwards without pre-operative, peri-operative and post-operative antibiotic usage were included. The study was conducted according to the latest Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-P protocols, the latest Cochrane Risk of Bias tool and each investigated intervention was evaluated using the grading of recommendation, assessment, development and evaluation (GRADE) system.

RESULTS

The search yielded 2718 results. After initial screening, 38 full-text articles were assessed for eligibility. From these, 11 studies satisfied all inclusion criteria. These 11 articles described six non-surgical and five surgical debridement therapies. Most articles were classified as having either a high risk of bias or presenting with some concerns. Small sample sizes, in combination with this risk of bias, meant that all interventions were adjudged to be of either low or very low quality of evidence.

CONCLUSION

While all investigated modalities displayed some sort of efficacy, this review suggests that a surgical approach may be best suited to treating peri-implantitis lesions in the absence of antibiotic therapy. Despite this weak indication, further research is required in this field.

Management of Peri-Implant Diseases: A Survey of Australian Periodontists

BACKGROUND/AIM

This survey-based study aims to explore the clinical management protocols of followed by Australian periodontists in relation to peri-implant diseases.

MATERIALS AND METHODS

A five-part online questionnaire was developed and administered through email. Descriptive statistics were used for analysis, with the univariate associations between a categorical outcome and the variables evaluated using Pearson's Chi-squared test.

RESULTS

The survey yielded 99 responses, resulting in a response rate of 41.8%. Most participants were male and aged 35-44 years. More than a quarter of practitioners had been placing implants for 6-10 years and almost two-fifths of practitioners placed 1-10 implants per month. The estimated prevalence of peri-implant mucositis and peri-implantitis in the general Australian population was 47% and 21%, respectively. Practitioners reported using systemic antibiotics to manage peri-implant mucositis (7%) and (72%) peri-implantitis lesions, with a combination of amoxicillin and metronidazole. Most common treatment modalities were oral hygiene instructions, nonsurgical debridement and antimicrobial gel/rinse. Surgical debridement and systemic antibiotics were also often used for peri-implantitis treatment. Practitioners preferred a 3-month clinical follow-up and 6-month radiographic evaluation. Furthermore, three-quarters of practitioners rated their management as moderately effective, although upwards of nine-tenths expressed the need for further training and awareness.

CONCLUSION

This study confirms a significant use of empirical treatment modalities due to lack of standard therapeutic protocol. However, some approaches followed by the specialists may provide a basis to formulate a therapeutic protocol for peri-implant disease management.

Bioactive Healing Abutment as a Potential Tool for the Treatment of Peri-Implant Disease—In Vitro Study

The common use of dental implants for dental reconstruction poses new treatment challenges for physicians, peri-implantitis being a particularly difficult one. Micro-organisms, including drug-resistant Staphylococcus spp. strains, play a crucial role in the etiology of peri-implantitis. In this paper, the authors assess the efficacy of a bioactive healing abutment (BHA) of their own design for the local release of antibiotics as a potential tool for the treatment of peri-implant disease. BHA filled with a collagen material, combined with the antibiotics clindamycin and tetracycline, was tested in vitro by disk diffusion assay. Antibacterial activity was observed for the chosen Staphylococcus aureus and Staphylococcus epidermidis bacterial strains. In addition, the impact of titanium discs (which were used to make the BHA) was monitored. The results show that the zone diameter breakpoints for BHA are higher than those of standard absorbent paper discs in both tested strains for both tested antibiotics. This work demonstrates that the proposed BHA can serve as an effective and precise drug carrier. The release of antibiotics from the described implant device is easy to control and allows for an effective local antibacterial in vitro treatment. The procedure is inexpensive, easy to perform, and repeatable.

Evaluation of adjunctive efficacy of diode laser in the treatment of peri-implant mucositis: a randomized clinical trial

Peri-implant disease may affect survival of dental implants. The aim of the study is to analyze the effectiveness of diode laser as a supportive modality to the non-surgical conventional treatment of peri-implant mucositis (PiM) and initial peri-implantitis (PI). Twenty-three patients with single implants suffering from PiM or initial PI were selected and randomly divided into two groups; control group (CG) received non-surgical conventional treatment, and test group (TG) received non-surgical conventional treatment and diode laser application with wavelength of 980 nm. Probing pocket depth (PPD) and bleeding on probing (BOP) were recorded at baseline (T0) and at 3 months follow-up (T1). The average of PPD value for TG was 4.04 ± 0.54 mm at T0 and it was 2.98 ± 0.70 mm at T1. In the CG, PPD average was 3.8 ± 1.24 mm at T0 and was 3.54 ± 0.35 mm at T1. In TG, the BOP was positive in 44 sites at T0 and in 6 sites at T1. In CG, the BOP was positively observed in 52 sites at T0 and in 28 sites at T1. The 980-nm diode laser may be considered an adjunct to the conventional non-surgical treatments of PiM and initial PI.

Simultaneous photoablative and photodynamic 810-nm diode laser therapy as an adjunct to non-surgical periodontal treatment: an in-vitro study

BACKGROUND

The use of lasers at different wavelengths has been proposed in combination with conventional non-surgical periodontal treatment in order to improve the clinical outcome of periodontal disease. However, the clinical use of laser photonic energy is still the subject of research and debate because the antibacterial activity of the laser is dependent upon method, laser parameters, quantity of bacteria, species selected and photosensitizers used.

METHODS

We evaluated the in-vitro bactericidal activity of 810 nm diode-laser irradiation in simultaneous photoablative and photodynamic mode against the major pathogenic bacterial organisms associated with periodontal inflammation and disease. We used indocyanine green as photosensitizer and the high-energy density of 161.7 J/cm2 or 215.0 J/cm2 for the photoablative-photodynamic irradiation.

RESULTS

The bacteria were drastically affected by the 215.0 J/cm2 irradiation in the presence of indocyanine green. In fact, the number of Porphyromonas gingivalis and Prevotella intermedia was reduced by 99.9% (P<0.001), while the number of Fusobacterium nucleatum, Aggregatibacter actinomycetemcomitans, Tannerella forsythia and Actinomyces viscosus decremented by 83.3% (P<0.01), 86.8% (P<0.05), 75% (P<0.01) and 78.7% (P<0.001), respectively. P. gingivalis and P. intermedia were the only bacteria that were sensitive to the treatment with indocyanine green dye and 161.7 J/cm2 of laser irradiation (P<0.001).

CONCLUSIONS

Our preliminary in-vitro data suggest that simultaneous photoablative-photodynamic irradiation could be a promising therapy against a wide range of bacteria involved in periodontal disease. We believe that further additional in-vivo investigation is necessary, to enable a more complete picture of effectiveness within a clinical setting to be established. In addition, the use of a simultaneous photoablative-photodynamic therapy is suggested to reduce treatment time, without compromising the efficacy against the periodontal pathogens.

Comparison of Bacterial Load Parameters in Subgingival Plaque during Peri-implantitis and Periodontitis Using the RT-PCR Method

Objective

To estimate the actual parameters of bacterial load in subgingival plaque during periodontitis and peri-implantitis pathologies using the RT-PCR (real-time polymerase chain reaction) method and evaluate their associations with clinical periodontal indicators.

Materials and Methods

Five different groups of subjects were selected according to a formulated design of the study: with mild/moderate periodontitis, with severe periodontitis, with peri-implantitis, healthy periodontal group and healthy peri-implant group. Subgingival plaque samples were formed with paper points inserted in the pocket/sulcus area for 30 seconds. A standardized test the “ParodontoScreen” was provided for identification of target opportunistic pathogens (A. actinomycetemcomitans, P. gingivalis, T. forsythia, P. intermedia, T. denticola) by the RT-PCR.

Results

Bacterial load parameters demonstrated a significant tendency towards an increase within periodontitis progression and during the presence of peri-implantitis pathology. Each targeted mean bacterial load level was statistically associated with periodontitis or peri-implantitis pathology (p < 0, 05) according to the provided univariate analyses and upon condition that bacterial load parameters of healthy sites were used as reference for equiparation. The highest correlation values were found between periodontal probing depth and bacterial load parameters of A. actinomycetemcomitans (r=0, 37; p < 0, 05) and P. gingivalis (r=0, 28; p < 0, 05); and also between clinical attachment loss and bacterial load values of A. actinomycetemcomitans (r=0, 38; p < 0, 05) and P. gingivalis (r=0, 24; p < 0, 05).

Conclusions

Periodontitis and peri-implantitis are associated with the same microbial pathogens even though the distribution pattern of their bacterial load and detection frequency parameters registered with RT-PCR could be distinct and linked to the individual patient-related conditions and the severity stage of pathology.

Antibiotic prescriptions in pediatric dentistry: A review

Most commonly prescribed drugs in pediatric dentistry are “Antibiotics.” Among Dentists, there is a trend toward overuse of antibiotics for nonindicated clinical conditions. This insufficient knowledge of the appropriate clinical indications for antibiotic prescriptions promotes the overuse of antibiotics and contributes to the emergence of antibiotic resistance among children. According to the various surveys done on the dental students, dentists and pediatric dentists on the antibiotic prescribing practices, overall, adherence to the professional clinical guidelines was low. There was a wide variation in dosages for all the antibiotics prescribed and for prolonged periods which were inconsistent with the recommendations. This paper reviews the current literature from the year 2000 to 2019. An electronic literature search was conducted in MEDLINE/PubMed, EBSCO host, and Google Scholar databases. The data was also collected manually from comprehensive textbooks. Some recommendations were also based on the opinion of experienced researchers and clinicians. Thus, this review aims at highlighting clinical indications, dosages, and duration of therapeutic antibiotic prescriptions for orofacial infections in the pediatric outpatients and at the same time creating an awareness, regarding the necessity of strictly adhering to the clinical guidelines for antibiotic prescriptions.

Effects of a novel gel containing 5-aminolevulinic acid and red LED against bacteria involved in peri-implantitis and other oral infections

Antibiotic resistance is a major public health problem worldwide and the finding of alternative methods for eliminating bacteria is one of the prerogatives of medical research. The indiscriminate use of antibiotics in dentistry, especially for the treatment of peri-implantitis, could lead to superinfections. Alternative methods, like photodynamic therapy mediated by the use of aminolevulinic acid and a red light has been largely described, especially in dentistry, but results were encouraging against Gram-positive bacteria, but limited against Gram-negative. The effectiveness of photodynamic therapy mediated by a novel product containing aminolevulinic acid, Aladent (ALAD) has been tested in this in vitro study, against different types of bacteria particularly involved in the infections of the oral cavity and peri-implantitis. The novelty of ALAD is the marked hydrophilicity that should increase the passage of the molecule through the membrane pores of Gram-negative bacteria. Considering the novelty of the product a preliminary experiment permitted to test the effectiveness against Enterococcus faecalis after 1 h of ALAD incubation at different concentrations, with or without different timings of LED irradiation. The count of CFUs and the live/dead observation with fluorescent microscopy showed a significant reduction and killing of bacterium. Then, in the second stage, that could meet the necessity of effectiveness and the clinician's requests to reduce the timing of treatment, ALAD, with and without irradiation, was tested on Staphylococcus aureus, Enterococcus faecalis, Escherichia coli, Veillonella parvula and Porphyromonas gingivalis. In particular, the efficiency of different concentrations of the product after a 25 min incubation was tested with and without the adjunctive LED irradiation for 5 min. A slight ALAD bactericidal effect was reported for all bacteria, also without LED irradiation, however, the most effective treatment was 25 min of 50% ALAD incubation followed by 5 min of a red LED. The in vitro tests demonstrated that ALAD gel with LED irradiation exerts a potent antibacterial activity on different bacteria, both Gram-positive and Gram-negative.

Facial cortical bone regeneration post-extraction in non-grafted sockets allows for early implant placement and long-term functional stability

OBJECTIVE

To evaluate posterior implant placement feasibility shortly after tooth extraction in non-grafted sockets with and without dehiscence at the time of extraction.

DESIGN

Ninety-five patients requiring posterior extractions entered this cross-sectional study. They were divided in three groups after extraction: G1 without dehiscence, G2 with dehiscence ≤5 and G3 > 5 mm. CBCT were taken prior to implant placement at an average of 12-weeks post-extraction to evaluate the need for grafting, cortical bone formation and bucco-lingual width (BLW). Actual BLW (n = 60) were compared to minimum expected BLW in 3 scenarios of BLW thickness averaging 6.4-7.4-8.4 mm. Peri-implant tissues were assessed for pocket formation and inflammation following established success criteria.

RESULTS

New cortical bone formation and sufficient BLW made implant placement feasible in sites with and without dehiscence at the time of extraction after an average healing time of 11.9 ± 2.4weeks (range: 8-18). Total average CBCT BLW was 10.1 ± 1.6 mm. All groups had a significantly higher BLW, than scenarios 1-3 (p < 0.0001). Molars were 20 times more likely than premolars to heal with BLW>10 mm (OR = 20; RR = 4.2; CI95 %: 5.3-74.2; p < 0.0001). Dehiscence sockets were 1.5 times more likely than non-dehiscenced sockets to present BLW ≤ 10 mm (OR = 1.5; RR = 0.6; CI95 %:0.9-2.5; p = 0.08). A band of keratinized tissue was present in all implants and success rates were 100 % at an average follow-up of 51.0 ± 23.4 months.

CONCLUSION

Implant placement is feasible without socket grafting shortly after tooth extraction. Non-grafted sockets present a significant osteogenic potential. Dehiscence sockets are likely to self-repair by forming a new cortical plate. The unassisted regenerated intra-socket bone allows for functional implant stability long-term.

Antimicrobial photodynamic therapy alone or in combination with antibiotic local administration against biofilms of Fusobacterium nucleatum and Porphyromonas gingivalis

Antimicrobial photodynamic therapy (aPDT) kills several planktonic pathogens. However, the susceptibility of biofilm-derived anaerobic bacteria to aPDT is poorly characterized. Here, we evaluated the effect of Photodithazine (PDZ)-mediated aPDT on Fusobacterium nucleatum and Porphyromonas gingivalis biofilms. In addition, aPDT was tested with metronidazole (MTZ) to explore the potential antimicrobial effect of the treatment. The minimum inhibitory concentration (MIC) of MTZ was defined for each bacterial species. Single-species biofilms of each species were grown on polystyrene plates under anaerobic conditions for five days. aPDT was performed by applying PDZ at concentrations of 50, 75 and 100 mg/L, followed by exposure to 50 J/cm² LED light (660 nm) with or without MTZ. aPDT exhibited a significant reduction in bacterial viability at a PDZ concentration of 100 mg/L, with 1.12 log₁₀ and 2.66 log₁₀ reductions for F. nucleatum and P. gingivalis in biofilms, respectively. However, the antimicrobial effect against F. nucleatum was achieved only when aPDT was combined with MTZ at 100× MIC. Regarding P. gingivalis, the combination of PDZ-mediated aPDT at 100 mg/L with MTZ 100× MIC resulted in a 5 log₁₀ reduction in the bacterial population. The potential antimicrobial effects of aPDT in combination with MTZ for both single pathogenic biofilms were confirmed by live/dead staining. These results suggest that localized antibiotic administration may be an adjuvant to aPDT to control F. nucleatum and P. gingivalis biofilms.

Multiparticulate based thermosensitive intra-pocket forming implants for better treatment of bacterial infections in periodontitis

Considering alarming projections in the prevalence of periodontitis, following study was undertaken to develop chitosan-vanillin crosslinked microspheres loaded in-situ gel (MLIG) implants containing ornidazole and doxycycline hyclate for the treatment of pocket infections. Firstly, microspheres were formulated and optimized using response surface methodology for particle size <50 μm, entrapment efficiency >80%, in-vitro drug release (T_80%) >7 days and acceptable mucoadhesion. Further, MLIG were optimized for gelation temperature of 34-37 °C and viscosity <1000 cps respectively. FTIR, DSC and XRD graphs disclosed compatibility and alterations in crystallinity of drugs. In-vitro dissolution study demonstrated non-Fickian type of drug release mechanism for twelve days. Stability studies ascertained MLIG implants were sterilizable and stable for about 11.29 months on refrigeration. The formulations exhibited significant (p < 0.001) antimicrobial activity against Staphylococcus aureus, Escherichia coli, and Enterococcus faecalis, and were found biocompatible and biodegradable during preclinical studies. Ligature-induced periodontal rat model, corroborated significant growth (p < 0.05) of gingival tissue after two weeks. Clinical trials revealed, intra-pocket administration of MLIG along with SRP provided significant reduction in clinical parameters as compared to SRP alone. Conclusively, antimicrobials incorporated thermosensitive, biodegradable, mucoadhesive and syringeable MLIG implants appeared as better option for the treatment of periodontitis.

Antibiotic Prescribing for Oro-Facial Infections in the Paediatric Outpatient: A Review

There are many reports on the complications associated with antibiotics abuse during the treatment of paediatric patients, particularly those related to antimicrobial resistance. The dental profession is no exception; there is growing evidence that dental practitioners are misusing antibiotics in the treatment of their paediatric patients. This review is directed to dental practitioners who provide oral healthcare to children. It is also directed to medical practitioners, particularly those working in emergency departments and encountering children with acute orofacial infections. A systematic search of literature was conducted to explore the clinical indications and recommended antibiotic regimens for orofacial infections in paediatric outpatients. The main indications included cellulitis, aggressive periodontitis, necrotizing ulcerative gingivitis, and pericoronitis. Amoxicillin was found to be the most commonly recommended antibiotic for short durations of 3–5 days, with metronidazole or azithromycin being the alternative antibiotics in penicillin-sensitive patients.

Graphene onto medical grade titanium: an atom-thick multimodal coating that promotes osteoblast maturation and inhibits biofilm formation from distinct species

The time needed for the osseointegration of titanium implants is deemed too long. Moreover, the bacterial colonization of their surfaces is a major cause of failure. Graphene can overcome these issues but its wet transfer onto substrates employs hazardous chemicals limiting the clinical applications. Alternatively, dry transfer technique has been developed, but the biological properties of this technique remain unexplored. Here, a dry transfer technique based on a hot-pressing method allowed to coat titanium substrates with high-quality graphene and coverage area >90% with a single transfer. The graphene-coated titanium is cytocompatible, did not induce cell membrane damage, induced human osteoblast maturation (gene and protein level), and increased the deposition of mineralized matrix compared to titanium alone. Moreover, graphene decreased the formation of biofilms from Streptococcus mutans, Enterococcus faecalis and even from whole saliva on titanium without killing the bacteria. These findings confirm that coating of titanium with graphene via a dry transfer technique is a promising strategy to improve osseointegration and prevent biofilm formation on implants and devices.

Patient Susceptibility to Candidiasis-A Potential for Adjunctive Immunotherapy

Candida spp. are colonizing fungi of human skin and mucosae of the gastrointestinal and genitourinary tract, present in 30-50% of healthy individuals in a population at any given moment. The host defense mechanisms prevent this commensal fungus from invading and causing disease. Loss of skin or mucosal barrier function, microbiome imbalances, or defects of immune defense mechanisms can lead to an increased susceptibility to severe mucocutaneous or invasive candidiasis. A comprehensive understanding of the immune defense against Candida is essential for developing adjunctive immunotherapy. The important role of underlying genetic susceptibility to Candida infections has become apparent over the years. In most patients, the cause of increased susceptibility to fungal infections is complex, based on a combination of immune regulation gene polymorphisms together with other non-genetic predisposing factors. Identification of patients with an underlying genetic predisposition could help determine which patients could benefit from prophylactic antifungal treatment or adjunctive immunotherapy. This review will provide an overview of patient susceptibility to mucocutaneous and invasive candidiasis and the potential for adjunctive immunotherapy.

Long-term stable vertical bone regeneration after sinus floor elevation and simultaneous implant placement with and without grafting

BACKGROUND

Less invasive surgical approaches to regenerate bone intra-sinus and allow long-term functional implant stability are needed.

PURPOSE

To evaluate long-term vertical bone regeneration after sinus floor elevation and simultaneous implant placement with and without bone grafting.

METHODS

Vertical bone gains (VBG) post-sinus elevation, with and without grafting, were evaluated in thirty individuals presenting an average residual bone height (RBH) of 4.2 mm using a standardized digital technique. Measurements were taken preoperatively, and at an average of 64.6 months follow-up. Clinically, peri-implant tissues were assessed for pocket formation and presence of inflammation to evaluate established success criteria.

RESULTS

Overall, RBH averaged 4.2 ± 1.1 mm (range: 1.8-5.8) and VBG 7.7 ± 1.6 mm (range: 6.0-12.9). Mean difference of 7.6 mm between vertical bone heights (VBH) at augmented implants sites and initial RBH, 11.8 versus 4.2 mm, (P < .0001, CI95%: 6.9-8.2) was statistically significant. RBH averaged 4.5 ± 0.8 mm and 3.8 ± 1.2 (P = .07) and VBG 6.8 ± 0.5 and 8.5 ± 1.9 mm (P = .003, CI95%: 0.6-2.7), for nongrafted and grafted individuals, respectively. The grafting group received an average graft volume of 0.35 ± 0.1 cc (range: 0.25-0.5) per implant site. Long-term follow-ups average 64.6 months (range: 36-144) and all implants met the success criteria. VBG ≥ 7 mm were 7.3 times more likely to develop on grafted sites (OR = 7.3, P = 0.02, CI95%: 1.2-46.2).

CONCLUSION

None to negligible amounts of grafting material are required to regenerate substantial amounts of autogenous bone into atrophic sinus cavities after simultaneous implant placement. The regenerated VBH seems stable for functional implant stability long-term. Implant success rates were 100% at an average of 64.6 months.

Porous Iron-Carboxylate Metal-Organic Framework: A Novel Bioplatform with Sustained Antibacterial Efficacy and Nontoxicity

Sustained drug release plays a critical role in targeting the therapy of local diseases such as bacterial infections. In the present work, porous iron-carboxylate metal-organic framework [MOF-53(Fe)] nanoparticles (NPs) were designed to entrap the vancomycin (Van) drugs. This system exhibited excellent chemical stability under acidic conditions (pH 7.4, 6.5, and 5.5) and much higher drug-loading capability because of the high porosity and large surface area of MOF NPs. The results showed that the drug-loading ratio of Van could reach 20 wt % and that the antibacterial ratio of the MOF-53(Fe)/Van system against Staphylococcus aureus could reach up to 90%. In addition, this MOF-53(Fe)/Van system exhibited excellent biocompatibility because of its chemical stability and sustained release of iron ions. Hence, these porous MOF NPs are a promising bioplatform not only for local therapy of bacterial infections but also for other biomedical therapies for tissue regeneration.