Periodontal disease as a primary cause of surgical site infection in fractures of the mandible: is smoking a confounding variable?

Fractures of the mandible are common in contemporary oral and maxillofacial practice. Wound infection is the most common complication after open reduction and internal fixation, and the management of these is complex and costly in terms of morbidity to the patient, and in fiscal terms. Whilst numerous epidemiological studies implicate smoking, alcohol, drug use, and adverse behaviour, as well as fracture complexity and diabetes, as important risk factors, the role of periodontal disease is only occasionally mentioned and not formally investigated. The aim of this study therefore was to assess the presence of periodontal disease and its severity according to the 2018 EFP/AAP periodontitis case classification in patients with fractured mandibles who presented to a single level 1 trauma centre, and to look for a possible association with surgical site infection. A total of 305 patients were assessed retrospectively following open reduction and internal fixation via transoral incisions with load-sharing osteosynthesis. The postoperative infection rate was 22.95%. Multivariate and multiple logistic regression revealed that there was a strong association between periodontal staging and postoperative surgical site infection. Crucially, the study predicts that patients with severe periodontal disease (periodontal stage III and IV) are over seven times more likely to develop a wound infection than disease-negative individuals. This has implications for risk adjustment, prognostication, treatment planning, and postoperative care. Surprisingly in this study, cigarette smoking, an established risk factor in the pathogenesis of periodontal disease, did not achieve statistical significance, potentially conflicting with the established literature.

An overview of periodontal regenerative procedures for the general dental practitioner

The complete regeneration of the periodontal tissues following periodontal disease remains an unmet challenge, and has presented clinicians with a remarkably difficult clinical challenge to solve given the extensive research in this area and our current understanding of the biology of the periodontal tissues. In particular as clinicians we look for treatments that will improve the predictability of the procedure, improve the magnitude of the effect of treatment, and perhaps most importantly in the long term would extend the indications for treatment beyond the need for single enclosed bony defects to allow for suprabony regeneration, preferably with beneficial effects on the gingival soft tissues. A rapid development in both innovative methods and products for the correction of periodontal deficiencies have been reported during the last three decades. For example, guided tissue regeneration with or without the use of bone supplements has been a well-proven treatment modality for the reconstruction of bony defects prior to the tissue engineering era. Active biomaterials have been subsequently introduced to the periodontal community with supporting dental literature suggesting that certain factors should be taken into consideration when undertaking periodontal regenerative procedures. These factors as well as a number of other translational research issues will need to be addressed, and ultimately it is vital that we do not extrapolate results from pre-clinical and animal studies without conducting extensive randomized clinical trials to substantiate outcomes from these procedures. Whatever the outcomes, the pursuit of regeneration of the periodontal tissues remains a goal worth pursuing for our patients. The aim of the review, therefore is to update clinicians on the recent advances in both materials and techniques in periodontal regenerative procedures and to highlight the importance of both patient factors and the technical aspects of regenerative procedures.