External validation of a clinical prediction tool for the use of manual therapy for patients with temporomandibular disorders: a protocol for a prospective observational study

INTRODUCTION

Clinical guidelines recommend conservative treatment for the management of temporomandibular disorders (TMD), and manual therapy directed to temporomandibular structures is commonly applied to reduce pain and improve function. In a recent prospective study, we developed a clinical prediction tool based on an array of predictors to identify people with TMD who are likely to experience significant pain relief and functional improvements following a programme of manual therapies (MTP) applied to temporomandibular structures. The purpose of this study is to externally validate in a different sample (temporal validation) the prediction model obtained in the initial study.

METHODS/ANALYSIS

This observational prospective study will recruit a cohort of 120 adults with TMD from a Dental Hospital in Italy. The intervention will be an MTP consisting of four sessions (once per week) of manual therapy applied to temporomandibular structures. Candidate predictors included in the predictive model will be pain intensity during mouth opening, treatment expectations, number of pain locations, central sensitisation, TMD pain duration and maximal mouth opening. Outcome measures (i.e., pain intensity, functional improvement) will be collected before starting the MTP, after the last session and after 1 month (2 months from baseline). A reduction of pain intensity by at least 30% will be considered a good outcome. External validity of the prediction model will be evaluated after the last session by measuring its calibration, discrimination and overall fit. Additionally, the performance of the model will be evaluated considering the clinical outcomes collected 1 month after the last MTP session.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the Ethics Committee of the Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Italy. The results will be submitted for publication in a peer-reviewed journal, and the prediction model will be implemented in a web-based calculator to facilitate its use by clinicians.

TRIAL REGISTRATION NUMBER

NCT03990662.

Maxillary Sinus Elevation by Crestal Window: Influence of 3D Sinus Size on Bone Regeneration-A Retrospective Clinical and Histologic Evaluation

This evaluation correlates maxillary sinus 3D morphology with bone regeneration. In 39 patients with crestal bone ≤ 2 mm, mineralized human bone allografts were used to augment the sinus floor through the crestal window sinus elevation approach. CBCT was used to measure the buccopalatal diameter (BPD), mesiodistal diameter (MDD), and hemi-ellipsoidal volume (Vh) in all sinuses. A bone core biopsy sample was taken at implant placement (4 to 5 months after sinus augmentation). Microradiographs of methacrylate-embedded sections were used to evaluate the amounts of bone, residual graft, and soft tissue. All 51 implants placed in the 39 patients successfully osseointegrated. A linear regression analysis showed that as BPD, MMD, and Vh increased, the amount of bone gain decreased and the amount of soft tissue increased (P < .05). The amount of residual graft was little affected by sinus morphology. Microradiographic data were grouped into four different sinus types (from small to great) using BPD and Vh medians. The best amount of bone formation was achieved in the narrow and short sinus type, while no great differences were found in the remaining three sinus types. Understanding of 3D sinus cavity morphology, especially the buccopalatal diameter and mesiodistal dimensions, is fundamental for achieving the best possible sinus augmentation outcomes.

Significant association between FGFR1 mutation frequency and age in central giant cell granuloma

Central giant cell granulomas (CGCG) are rare intraosseous osteolytic lesions of uncertain aetiology. Despite the benign nature of this neoplasia, the lesions can rapidly grow and become large, painful, invasive, and destructive. The identification of molecular drivers could help in the selection of targeted therapies for specific cases. TRPV4, KRAS and FGFR1 mutations have been associated with these lesions but no correlation between the mutations and patient features was observed so far. In this study, we analysed 17 CGCG cases of an Italian cohort and identified an interesting and significant (p=0.0021) correlation between FGFR1 mutations and age. In detail, FGFR1 mutations were observed frequently and exclusively in CGCG from young (<18 years old) patients (4/5 lesions, 80%). Furthermore, the combination between ours and previously published data confirmed a significant difference in the frequency of FGFR1 mutations in CGCG from patients younger than 18 years at the time of diagnosis (9/23 lesions, 39%) when compared to older patients (1/31 lesions, 0.03%; p=0.0011), thus corroborating our observation in a cohort of 54 patients. FGFR1 variants in young CGCG patients could favour fast lesion growth, implying that they seek medical attention earlier. Our observation might help prioritise candidates for FGFR1 testing, thus opening treatment options with FGFR inhibitors.

The impact of Covid-19-related distress on general health, oral behaviour, psychosocial features, disability and pain intensity in a cohort of Italian patients with temporomandibular disorders

This study aimed to understand the impact of COVID-19 distress on psychological status, features of central sensitization and facial pain severity in people with temporomandibular disorders (TMDs). In this prospective cohort study, 45 adults (19 chronic, 26 acute/subacute TMD) were recruited prior to the COVID-19 outbreak. Baseline assessment took place before the outbreak while a follow-up was performed immediately after the lockdown period. Multiple variables were investigated including age, gender, perceived life quality, sleep quality, anxiety and depression, coping strategies, central sensitization, pain intensity, pain-related disability and oral behaviour. COVID Stress Scales (CSS) were applied at follow-up to measure the extent of COVID-related distress. CSS were significantly higher in those with chronic TMDs compared to those with acute/subacute TMDs (p<0.05). In people with chronic TMD, the variation in anxiety and depression from baseline to follow-up was significantly correlated with scores on the CSS (r = 0.72; p = 0.002). Variations of the central sensitization inventory (r = 0.57; p = 0.020) and graded chronic pain scale (r = 0.59; p = 0.017) were significantly correlated with scores on the CSS. These initial findings indicate that people with chronic TMD were more susceptible to COVID-19 distress with deterioration of psychological status, worsening features of central sensitization and increased chronic facial pain severity. These findings reinforce the role of stress as a possible amplifier of central sensitization, anxiety, depression, chronic pain and pain-related disability in people with TMDs. Trial Registration: ClinicalTrials.gov ID: NCT03990662.

Predictors of pain reduction following manual therapy in patients with temporomandibular disorders: a protocol for a prospective observational study

INTRODUCTION

Temporomandibular disorders (TMDs) are principally characterised by pain in the craniomandibular area and probable limitations of jaw opening. Manual therapy, like other recommended conservative treatments included in clinical guidelines, is commonly used to treat patients with TMD to reduce pain and improve function. However, outcomes may be variable. The aim of this study is to identify predictors associated with pain reduction in patients with TMD following manual therapy by analysing a combination of patient-reported outcome measures and clinical tests. Such knowledge will support a more personalised management approach by facilitating clinical decision-making.

METHODS/ANALYSIS

An observational prospective design will recruit a cohort of 100 adults with a diagnosis of TMD (according to Axis I of the Diagnostic Criteria for TMD) at a Dental Hospital in Italy. Patients will be treated with four weekly sessions of manual therapy applied to craniomandibular structures. An array of predictors has been chosen based on previous research on prognostic factors for TMD and altered pain modulation in musculoskeletal disorders. Candidate predictors including demographic variables, general health variables, psychosocial features, TMD characteristics and clinical tests of the temporomandibular joint and masticatory muscles will be collected at baseline. Definition of good outcome is a clinically significant reduction of pain intensity over the last week (≥30% reduction Visual Analogue Scale) immediately following the four week intervention. Exploratory factor analysis will be applied to analyse factor loading of candidate predictors for good outcome at four weeks. Subsequently, a logistic multivariable regression model will be performed to calculate low and high risk of good outcome.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the 'Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico' and University of Birmingham Ethics Committee. The results will be submitted for publication in a peer-reviewed journal and presented at conferences.

TRIAL REGISTRATION NUMBER

NCT03990662; Pre-results.

Speed bleaching: the importance of temporary filling with hermetic sealing

The aim of this study was to demonstrate the influence of an adhesive temporary restoration on the effectiveness of the bleaching reaction, regardless of the concentration of the bleaching agent used. Every clinician involved in conservative dentistry understands the incompatibility between 'chemical bond' and 'oxygen.' This awareness often influences clinicians to decide on a temporary 'mechanical retention' filling that is unable to prevent the escape of oxygen ions, forcing the patient into more sessions and therefore raising the risk of complications. The scientific rationale behind the procedure described in this article is based on the bonding capacity of the coronal seal to maintain the rapid dissociation of the hydrogen peroxide exclusively within the pulp chamber, inducing an increase in the internal pressure and a consequent penetration of the oxygen-free radicals directly inside the dentinal tubules. In fact, avoiding the spontaneous dissipation of the oxygen-free radicals in the external environment may limit their effectiveness. This study aimed specifically to prove that it is possible to obtain a rapid bleaching reaction by observing a protocol based on the 'walking bleach' technique, specifically modified not so much by the typology of the mixture used but by fully exploiting the reaction yield of the hydrogen peroxide disproportionation. The results of the documented clinical cases presented here show the effectiveness of this method, which is achieved in a single session, therefore decreasing the possibility of the several operating phases that are necessary with the traditional procedure.

A new surgical and technical approach in zygomatic implantology

Purpose

Different surgical approaches for zygomatic implantology using new designed implants are reported.

Material and methods

The surgical technique is described and two cases reported. The zygomatic fixture has a complete extrasinus path in order to preserve the sinus membrane and to avoid any post-surgical sinus sequelae.

Results

The surgical procedure allows an optimal position of the implant and consequently an ideal emergence of the fixture on the alveolar crest.

Conclusion

The surgical procedures and the zygomatic implant design reduce remarkably the serious post-operative sequelae due to the intrasinus path of the zygomatic fixtures.

Flapless Versus Traditional Dental Implant Surgery: Long-Term Evaluation of Crestal Bone Resorption

PURPOSE

The literature reports that flapless compared with traditional implant surgery can be associated with several advantages, including the maintenance of peri-implant hard tissues. This study investigated vertical bone resorption during long-term follow-up after implant placement with flapless versus traditional surgery.

MATERIAL AND METHODS

In this prospective, randomized controlled clinical trial, 40 patients underwent implant placement at the Maxillofacial Department Surgery of the Istituto Stomatologico Italiano Hospital in Milan, Italy. Patients were randomly assigned to the control or experimental group. The control group had implants placed with open flap surgery (traditional surgery), whereas the experimental group had implants placed with flapless surgery. The distance between the first implant thread and the marginal crestal bone level was measured at the basal, loading, and long-term control points. The basal recording was performed just after implant placement. The loading measurement was recorded at the time of implant loading, after 2 months of healing for the lower jaw and after 3 months of healing for the upper jaw, and the long-term control record was registered 36 months after implant placement. Statistical analysis was performed using mean values and standard deviations based on bone resorption in the 2 groups. To detect statistical differences, the Student t test was applied. Differences were considered significant if P values were less than .05.

RESULTS

The control group (open flap surgery) was comprised of 19 patients, and the experimental group (flapless surgery) was comprised of 21 patients. No statistical differences were found in peri-implant bone resorption between the 2 groups at the basal, implant loading, and 3-year control recordings.

CONCLUSION

According to this study, the approach to implant surgery does not seem to influence peri-implant bone resorption in humans, at least for the period measured in this study.

The effect of palm oil addition to the diet of dairy sheep on the immune response

The aim of this study was to evaluate whether a diet based on palm oil has any influence on the immune response and on the number of eggs per gram of faeces (EPG) of gastrointestinal nematodes (GIN) in dairy sheep. To address this issue, 30 ewes in early lactation were confined and divided into three groups (n = 10) receiving a daily isoproteic and isoenergetic diet. Palm oil was added to the feed at different concentrations: 0% (control; group A), 4% (group B) and 6% (group C). The animals were treated with levamisole 10 days before the beginning of the experiment. Faecal samples were collected and analysed for EPG on day zero of the experiment. On days 60 and 120, individual faecal and blood samples were collected, and the FAMACHA(©) score for assessing clinical anaemia was carried out. The groups receiving palm oil showed a significant reduction in EPG in relation to the control group (A) on day 120. Serum immunoglobulin levels (IgG, IgM and IgE) and proinflammatory cytokine levels (TNF-α, IL-1 and IL-6) were significantly increased on days 60 and 120 (p < 0.05) in groups B and C. Therefore, these results suggest that palm oil stimulates the immune response in sheep, thus reducing EPG of GIN. The hypothesis that palm oil has direct anthelmintic activity should be tested in future studies.

Clinical and radiographic evaluation of immediately loaded one-piece implants placed into fresh extraction sockets

OBJECTIVE

To assess clinical survival and success rates of one-piece implants placed at the time of tooth extraction with immediate provisionalization and to evaluate radiographic peri-implant bone loss around one-piece implants 1 year after functional loading.

METHOD AND MATERIALS

Forty-six patients (20 men and 26 women) with a mean age of 45.5 years (range, 24 to 74 years) were recruited from four centers for this case series report. Immediately following the extraction of untreatable teeth, all patients received one-piece implants. The implants were immediately restored and placed into function with no occlusal contact. Outcome assessments included clinical and radiographic evaluations.

RESULTS

Of the one-piece implants placed after extraction in the maxilla and mandible, 95.7% integrated successfully. The mean marginal bone loss after 1 year was 0.80 mm (SD, 0.53 mm). Overall peri-implant bone loss at maxillary sites was compared with overall bone loss at mandibular sites. At the 1-year follow-up, no statistically significant difference was found. The deeper the implants were placed below the crest, the more marginal bone loss was observed. However, no difference in marginal bone loss was observed as a consequence of the following three variables: implant length (10, 11.5, or 13 mm), implant diameter (3, 3.7, or 4.7 mm); and 3- and 6-month time periods after implant prosthesis placement.

CONCLUSION

Based on data obtained from this sample size study, it can be concluded that one-piece implants can be successfully placed immediately after extraction with minimal peri-implant bone loss.

Factors affecting bone response around loaded titanium dental implants: A literature review

This paper was designed as a review of the knowledge concerning bone adaptation around dental implants. Current literature concerning the biomechanics of bone and titanium dental implants as a main focus and pertinent to key aspects of the review was taken into consideration. Implant stiffness, design and surface were considered as factors affecting bone response to loaded dental implants. The emerging data allows the conclusion that implant design influences force transmission to periimplant bone, but seems to have poor power in preventing time-related marginal bone crest resorption. Mechanical stimulation such as prosthetic stress-dependent strains, affects bone tissue adaptation. Therefore, it is crucial to have high biomechanical control on implants to preserve implant ankilosis and to promote periimplant bone deposition.

In vitro and in vivo follow-up of titanium transmucosal implants with a zirconia collar

The advantages of transmucosal healing implants with a bioactive zirconia collar as a support for partially fixed prosthodontic restorations are optimal peri-implant marginal tissue sealing, reduction in plaque accumulation and satisfactory aesthetic results. The zirconia used in this study evidenced not only optimal clinical performances, but also good biocompatibility. The results from this study demonstrated that zirconia coating enhances fibroblasts and osteoblast-like cell adhesion, spreading and proliferation, favoring microscopic tissue/cell in-growth and clinical implant fixation improvement. From clinical analysis, it emerged that the treatment group obtained better scores in every peri-implant parameter. This evidence attests faster stabilization of soft and hard tissues around both the transmucosal zirconia collar and at the crestal level of the implant. A reduced plaque accumulation around the implant with zirconia collar could provide a better peri-implant microbiological en-vironment by allowing the soft tissues expression of optimal sealing and good bone adaptation to loading. From these clinical and radiographic comparative analyzes, it emerged that in the treatment group the mean values were always similarly low. A rapid stabilization of both hard and soft peri-implant tissues was documented in the 1st yr. In the treatment group, there was the formation of stable tissue sealing the zirconia collar, which could preserve mucosal and bone levels. In conclusion, 2-yr clin-ical results demonstrated that implants supporting fixed restorations using transmucosal healing implants with a zirconia collar appeared a valid method, reporting 100% implant survival rates. Moreover, in vivo results obtained using strict parame-ters to assess the peri-implant status affirmed that a zirconia collar offers excellent biological acceptance. Our preliminary in vitro results statistically evidenced increased fibroblast and osteoblast adhesion and proliferation to zirconia compared to tita-nium, and an index of enhanced material integration with bone and soft tissue cells. (Journal of Applied Biomaterials & Biomechanics 2004; 2: 143-50).

Morphostructural relationships between bone and implant: comparative analyses by optical microscopy and microradiography

This study assessed the relationship between the surfaces of a hollow cylindrical titanium implant and the consequent bone organization around it. A human bone maxillary specimen was taken that enclosed an implant which had lasted 28 months under prosthetic loading. The implant was removed because of fracture that prevented the implant from being used as a supporting element for new prosthetic aims. The bone block-section was fixed and embedded, several sections were obtained, and each section was analyzed using three different histologic analyses: optical microscopy under ordinary light and polarized light, and microradiography. Comparative analyses were required on every single section to provide a complete morphostructural analysis of the peri-implant bone. Data retrieved by this research showed the presence of woven bone in the bone layer facing the external implant surface several months after its surgical fitting and functionalization. This finding demonstrates the importance of woven bone, first as holding sheath in the immediate postsurgical stage, and second as a mold for the subsequent centripetal accrementition of secondary lamellar bone.