Association between smoking and peri-implant diseases: A retrospective study

OBJECTIVES

To determine the association between tobacco and peri-implant diseases in a sample of patients who had received implant-supported restorations in a university dental clinic. Furthermore, the study aimed to investigate patient- and implant-related variables associated with peri-implant diseases.

MATERIALS AND METHODS

The present retrospective study analyzed data from 117 patients treated with implant-supported restorations from 2001 to 2013. A total of 450 implants were evaluated. Patients were selected from an electronic database, and patient- and implant-related variables were evaluated. Detailed information regarding the smoking history (i.e., smoking status, lifetime cumulative dose, duration of exposure, intensity of the habit, and smoking cessation) was recorded. The primary study outcome was peri-implant status [i.e., health (H), peri-implant mucositis (PM) and peri-implantitis (PI)]. Univariate and multinomial regression models comparing PM and PI versus peri-implant health were conducted.

RESULTS

A total of 117 subjects [55 (47%) females and 62 (53%) males] with a mean age at examination of 64.2 years (SD 11.6) and rehabilitated with 450 implants were included. The average number of implants per patient was 4.6 (SD 3.3) with a mean time in function of 8.0 years (SD 1.9). Fifty-six patients (47.9%) were non-smokers, 42 (35.9%) were former-smokers, and 19 (16.2%) were current-smokers. Thirty-nine subjects (33.4%) were H, whereas 41 (35%) and 37 (31.6%) exhibited PM and PI, respectively. At implant level, the corresponding values were 142 (31.6%), 230 (51.1%) and 78 (17.3%). In the multinomial regression model, significant associations for peri-implant diseases were observed for the mean number of implants per patient (p = .016), function time (p = .048), implants placed simultaneously with guided bone regeneration (p = .016), implant surface (p = .020), keratinized mucosa at the buccal aspect (p = .032), and access to interproximal hygiene (p < .001). In addition, ever smokers >23 pack-years exhibited a significantly higher risk for peri-implantitis (p = .002). Finally, the multinomial regression analysis revealed that subjects who had stopped smoking more than 21 years before the last examination presented a significantly lower risk of peri-implant diseases than a smoking cessation of ≤21 years (p = .028).

CONCLUSIONS

Smoke intensity was associated with an increased risk of the development of peri-implantitis. Moreover, the risk of peri-implant diseases might be similar in those subjects who had stopped smoking for more than 21 years with respect to never-smokers.

Comparative 16S rRNA gene sequencing study of subgingival microbiota of healthy subjects and patients with periodontitis from four different countries

AIM

To investigate the differences between the subgingival microbiota of healthy subjects (HS) and periodontitis patients (PP) from four different countries through a metagenomic approach.

MATERIALS AND METHODS

Subgingival samples were obtained from subjects from four different countries. Microbial composition was analysed through high-throughput sequencing of the V3-V4 region of the 16S rRNA gene. The country of origin, diagnosis and clinical and demographic variables of the subjects were used to analyse the microbial profiles.

RESULTS

In total, 506 subgingival samples were analysed: 196 from HS and 310 from patients with periodontitis. Differences in richness, diversity and microbial composition were observed when comparing samples pertaining to different countries of origin and different subject diagnoses. Clinical variables, such as bleeding on probing, did not significantly affect the bacterial composition of the samples. A highly conserved core of microbiota associated with periodontitis was detected, while the microbiota associated with periodontally HS was much more diverse.

CONCLUSIONS

Periodontal diagnosis of the subjects was the main variable explaining the composition of the microbiota in the subgingival niche. Nevertheless, the country of origin also had a significant impact on the microbiota and is therefore an important factor to consider when describing subgingival bacterial communities.

Could dietary restrictions affect periodontal disease? A systematic review

OBJECTIVE

This review aimed at evaluating the possible benefits that caloric restriction (CR) may provide to periodontal disease progression and response to treatment.

MATERIAL AND METHODS

Electronic search on Medline, Embase and Cochrane, and manual search were performed to identify pre-clinical and on human studies reporting the consequences of CR on clinical and inflammatory parameters related to periodontitis. Newcastle Ottawa System and SYRCLE scale were used to assess the risk of bias.

RESULTS

Four thousand nine hundred eighty articles were initially screened, and a total of 6 articles were finally included, consisting of 4 animal studies and 2 studies in humans. Due to the limited number of studies and heterogeneity of the data, results were presented in descriptive analyses. All studies showed that, compared to the normal (ad libitum) diet, CR might have the potential to reduce the local and systemic hyper-inflammatory state as well as disease progression in periodontal patients.

CONCLUSIONS

Within the existing limitations, this review highlights that CR showed some improvements in the periodontal condition by reducing the local and systemic inflammation related to the periodontitis and by improving clinical parameters. However, the results should be interpreted with caution since robust research such as randomized clinical trials is still missing.

CLINICAL RELEVANCE

This review shows that some dietary/caloric restrictions approaches may have the potential to improve periodontal conditions and, in addition, highlights a need for human studies with a robust methodology in order to draw stronger evidence-based conclusions.

Digital evaluation of facial peri-implant mucosal thickness and its impact on dental implant aesthetics

OBJECTIVE

The aim of the present study was to describe and compare the features of the buccal peri-implant mucosa to natural gingiva in the aesthetic area.

MATERIAL AND METHODS

Forty-nine periodontally healthy patients were included in this cross-sectional study. Mucosal and gingival dimensions at the mid-facial aspect were evaluated clinically and radiographically. Color assessments were performed using a reflectance spectrophotometer, and patient aesthetic satisfaction was further checked.

RESULTS

Implant sites revealed significant thicker mucosa when compared to tooth sites both at 1.5 (p < 0.001) and 3 mm (p < 0.001) apical to the mucosal margin. Both conventional and digital methods presented a good reliability. The spectrophotometric data revealed a statistically significant color difference between the peri-implant mucosa and the gingiva. However, there was no further significant relation between these color changes and the mucosal thickness.

CONCLUSIONS

Peri-implant mucosa revealed a darkish, greenish, and bluish discoloration when compared to the gingiva. More satisfactory patient´s aesthetic evaluation was reported in sites with thicker and comparatively lighter mucosa when compared to the adjacent dentition.

CLINICAL RELEVANCE

This article focuses on variables affecting color stability and aesthetics around dental implants. These can be assessed to identify the need for peri-implant phenotypic modification.

Influence of vestibular depth on the outcomes of root coverage therapy: A prospective case series study

BACKGROUND

The purpose of this study was to investigate the influence of vestibular depth (VD) on the outcomes of root coverage therapy.

METHODS

Patients presenting gingival recession defects (GRD) with a minimum depth of 2 mm underwent root coverage therapy consisting of a coronally advanced flap plus a connective tissue graft (CAF + CTG). Clinical examinations were performed, and intraoral scans were obtained at baseline, 3 and 6 months after surgery to assess changes in probing depth (PD), keratinized tissue width (KTW), recession depth (RD), GRD area, marginal gingival thickness (MGT), and VD. The influence of VD on percentage of root coverage (%RC) and the likelihood of achieving complete root coverage (CRC) were explored.

RESULTS

A total of 20 patients were enrolled, and 44 teeth were treated. RD decreased and MGT increased in all treated sites. At 6 months, mean %RC was 87.47 ± 18.37 and CRC was observed in 61.4% of sites. Mean baseline VD was 7.33 ± 2.67 mm. Mean VD reduction from baseline to 6 months was 1.98 ± 1.27 mm. %RC and CRC were significantly correlated with baseline VD. Each additional 1 mm of baseline VD implied a gain of 6.58% for %RC and increased 2.75 times the probability of achieving CRC. Narrow baseline KTW and mandibular arch location were associated with inferior treatment outcomes.

CONCLUSION

Lower %RC and likelihood of achieving CRC can be expected after root coverage therapy via CAF + CTG in sites presenting a shallow vestibulum.

Dimensional Alterations Following Immediate Implant Placement Using the Socket-Shield Technique in the Anterior Maxilla: A Case Series

Tissue volume loss after tooth extraction is an esthetic challenge. The socket-shield technique (SST) has been used to compensate it with promising results but limited evidence. This prospective study aims to present the dimensional changes after SST. Ten consecutive patients with an anterior hopeless tooth to be extracted and an immediate implant placed using the SST were prospectively enrolled. An impression and a CBCT scan were taken prior to surgery and 6 months later. Models were scanned, and DICOM and STL (standard tessellation language) files were superimposed and analyzed by software to measure the dimensional differences. Five patients could be evaluated for bone alterations and 9 for soft tissue alterations. The mean horizontal shrinkage of the buccal bone plate at 1 mm from the most coronal part was -0.22 ± 0.13 mm in the CBCT analysis. The mean volume loss in the region of interest was -2.94 ± 2.45 mm³, with a mean change in soft tissue contours of -0.49 ± 0.41 mm between pre- and postoperative analysis. SST limited the buccal contour loss after tooth extraction and may be considered a potential option to prevent volume loss in immediate implant placement. Further standardization in the digital measurement method is still needed.

Efficacy of soft tissue augmentation procedures on tissue thickening around dental implants: A systematic review and meta-analysis

OBJECTIVES

The first focused question (FQ1) was: What is the efficacy of connective tissue graft (CTG), as compared to the absence of soft tissue grafting procedure, in terms of gain in peri-implant soft tissue thickness (STT) reported by randomized controlled clinical trials (RCTs) or controlled clinical trials (CCTs)? The second focused question (FQ2) was: What is the efficacy of CTG, as compared to soft tissue substitutes, in terms of gain in peri-implant STT reported by RCTs or CCTs?

MATERIALS AND METHODS

A manual and electronic search was performed for each question to identify RCTs and CCTs published up to July 2020. The primary outcome variable was changes in peri-implant STT and secondary outcomes were marginal bone level (MBL), clinical parameters for the diagnosis of peri-implant health, changes in the position of peri-implant soft tissues, esthetic outcomes, and patient-related outcome measures (PROMs). For primary and secondary outcomes, data reporting mean values and standard deviations for each study were extracted. Weighted mean differences (WMDs) or standardized mean differences as well as 95% confidence intervals (CIs) and prediction intervals (PIs) were calculated.

RESULTS

Eight trials were included to answer the first focused question and eight to answer the second one, providing data for 254 and 192 patients, respectively. For the first focused question, a statistically significant difference of 0.64 mm in STT was found in favor of the grafted group (n = 8; 95% CI [0.16; 1.13]; 95% PI [-1.06; 2.35]; p = .01). Moreover, sites treated with CTG exhibited statistically significant less recession than implants without a graft (n = 4; WMD = 0.50 mm; 95% CI [0.19; 0.80]; 95% PI [-0.70; 1.69]; p < .001). For the second focused question, the meta-analysis showed a statistically significant gain of STT in the CTG group when compared to soft tissue substitutes (n = 8; WMD = 0.51 mm; 95% CI [0.28; 0.75]; 95% PI [-0.09; 1.12]; p < .001). Furthermore, the use of CTG resulted in significantly higher pink esthetic score values (n = 3; WMD = 1.02; 95% CI [0.29; 1.74]; 95% PI [-3.67; 5.70]; p = .01) and less recession (n = 2; WMD = 0.50 mm; 95% CI [0.10; 0.89]; 95% PI [not estimable]; p = .014) when compared to soft tissue substitutes. No statistically significant differences between groups were observed for any of the following secondary variables: MBL, clinical parameters for the diagnosis of peri-implant health, position of the interproximal tissues, keratinized mucosa or PROMS (p > 0.05), except for medication intake, which was significantly higher when using CTG as compared to soft tissue substitutes (n = 2; WMD = 1.68; 95% CI [1.30; 2.07]; 95% PI [not estimable]; p < .001).

CONCLUSIONS

Soft tissue augmentation procedures are efficacious on soft tissue thickening and, in particular, CTG demonstrated a significant STT gain when compared to no graft or soft tissue substitutes.

Impact of smoking on peri-implant bleeding on probing

BACKGROUND

Studies around natural dentition demonstrated that smoking can reduce the tendency of inflamed tissue to bleed upon probing after controlling for possible confounders. In addition, previous research suggested that smokers may present alterations of the peri-implant microbiome.

AIM

This study aimed at investigating the impact of smoking on: (1) peri-implant bleeding on probing (BOP; primary objective); (2) the association between BOP/bone loss and BOP/visible gingival inflammation; (3) peri-implant microbiome.

METHODS

Partially edentulous patients with implants restored with a single crowns were included in this study. Subjects were either smokers (≥1 cigarettes per day) or nonsmokers (never smokers). The primary outcome of this cross-sectional study was BOP and secondary outcomes included: Probing pocket depth (PPD), Modified gingival Index (mGI) and Progressive Marginal Bone Loss. In addition, microbial profiles of the subjects were assessed through sequencing of the 16S rRNA gene. Univariate and multilevel multivariate analyses by means of Generalized Estimating Equations were conducted to analyze the association between smoking and peri-implant BOP.

RESULTS

Overall, 27 nonsmokers and 27 smokers were included and 96.3% and 77.78% of patients presented peri-implant BOP in the nonsmoker and smoker group, respectively (p = 0.046). Smoking was inversely associated with BOP in the multivariate multilevel analysis (OR = 0.356; 95% CI: 0.193-0.660; p = 0.001) whereas a positive correlation was demonstrated for mGI > 0 (OR = 3.289; 95% CI: 2.014-5.371; p < 0.001); PPD (OR = 1.692; 95% CI: 0.263-0.883; p = 0.039) and gender (OR = 2.323; 95% CI: 1.310-4.120 p = 0.004). A decrease of BOP sensitivity in detecting visible gingival inflammation (mGI > 0) was observed in smokers. Besides, taxonomic and changes in diversity regarding the peri-implant microbiota were detected comparing the two groups. Significantly higher richness of the microbiota was demonstrated in the smoker group when implants affected by peri-implantitis were compared to either healthy implants or implants presenting mucositis.

CONCLUSIONS

Smoking is a potential modifier of BOP and peri-implant microbiota.

Periodontists' Trends in the Management of Peri-implant Diseases

PURPOSE

The scarce standard therapeutic protocols for the management of peri-implant diseases results in the empirical application of therapeutic modalities. The objective of this study was to carry out a survey to analyze the therapeutic trends of professionals with different academic backgrounds and levels of expertise.

MATERIALS AND METHODS

An exploratory cross-sectional internet-based study survey of board-certified members of the American Academy of Periodontology (AAP) and the European Federation of Periodontology (EFP) was conducted. To assess the therapeutic trends, four clinical vignettes representing different scenarios of peri-implant biologic complications were provided to the participants. Differences in practice patterns were determined using chi-square test and Student t test or analysis of variance (ANOVA) test for qualitative variables.

RESULTS

A total of 268 members of the AAP and EFP completed the survey. A significant difference in preferred treatment plan was found between EFP and AAP periodontists, resective therapy being the treatment of choice by the majority of the former (41.2%) and regenerative therapy by the latter (48.9%; P < .001). Overall, 48.1% of experts did not consider any intervention for the management of mucositis. Antibiotic prescriptions differed among groups, with statistical significance in each clinical case, and the explantation criteria were inconsistent and differed significantly among groups.

CONCLUSION

Substantial variations exist concerning the decision-making to manage peri-implant diseases and conditions.

Keratinized mucosa changes around one-stage implants: A prospective case series

BACKGROUND

The need of an adequate band of keratinized tissue (KT) to maintain periodontal health around teeth as well as around implants has been a debated topic over many years but still no conclusions have been drawn.

OBJECTIVES

This prospective case series evaluates the changes undergone by the keratinized mucosa (KM) and the soft tissue volume around non-submerged implants before the prosthetic rehabilitation.

MATERIAL AND METHODS

A total of 40 patients were included. The primary outcome was to analyze the width of the KM at both buccal and lingual aspects compared to the pre-existing KT in the edentulous ridge only in mandibular (pre)molar area. The mucogingival line was marked with a surgical pen and an intra-oral scanner was used to take the impression of the implant area the day of the surgery (T0, baseline) and before the crown placement (T1, 3 months). Buccal soft tissue volume was measured at 1, 3, and 5 mm apical to the healing abutment position and a comparison between T0 and T1 was performed. Student t-test was used according to the distribution of the data (Shapiro-Wilk).

RESULTS

The mean KT width at baseline was 4.54 ± 1.31 mm at buccal side and 5.04 ± 1.88 mm at lingual side. After 3 months, the mean KM values were 3.15 ± 1.03 mm and 3.72 ± 1.56 mm at the buccal and lingual aspects, respectively. The differences, 30.6% of KM reduction buccally and 26.1% of reduction lingually, were statistically significant for both sides.

CONCLUSIONS

Within the limitations of this investigation, it was observed that the KM width from the baseline to the 3 months follow up presented a significant dimensional change in both the buccal and lingual aspects, whereas buccal soft tissue volume showed an increase between baseline and follow up.

Is systemic inflammation a missing link between periodontitis and hypertension? Results from two large population-based surveys

OBJECTIVE

The primary objective was to investigate the relationship between periodontitis and hypertension in two independent large surveys. The secondary objective was to ascertain whether systemic inflammation had a mediation effect in the association.

METHODS

This cross-sectional study analysed representative samples of the US (n = 3460; NHANES 2009/10) and Korean (n = 4539; 2015 KNHANES VI-3) populations. The association between periodontitis (exposure), hypertension (outcome) and inflammatory markers [C-reactive protein (CRP) and white blood cell counts (WBC)] (mediators) was assessed using multivariate linear and logistic regression models and mediation analysis.

RESULTS

Participants with periodontitis were more likely to have hypertension (NHANES: OR = 1.3, 95% CI: 1.0-1.6, P = 0.025; KNHANES: OR = 1.2, 95% CI: 1.0-1.4, P = 0.041) and actual systolic blood pressure ≥ 140 mmHg (NHANES: OR = 1.6, 95% CI: 1.1-2.3, P < 0.001; KNHANES: OR = 1.3, 95% CI :1.0-1.6, P < 0.031) than those without the disease. These associations were independent of age, gender, BMI, education level, smoking, alcohol consumption, creatinine, physical activity, presence of other comorbidities and confirmed in participants not taking antihypertensive medications. Diagnosis of periodontitis was directly associated with WBC (in both surveys: NHANES: β ± SE = 0.3 ± 0.1, P < 0.004; KNHANES: β ± SE = 0.3 ± 0.1, P < 0.001) and with CRP levels (in one survey: NHANES: β ± SE = 0.1 ± 0.03, P < 0.007; KNHANES: β ± SE = 0.1 ± 0.04, P > 0.213). Mediation analyses confirmed that CRP acted as a mediator in the association between periodontitis and hypertension in both populations (mediated effect: NHANES: β ± SE = 0.010 ± 0.003, P < 0.001; KNHANES: β ± SE = 0.003 ± 0.001, P = 0.015). WBC acted as a mediator in the KNHANES (mediated effect: β ± SE = 0.004 ± 0.001, P = 0.004) whilst in the NHANES, its effect was dependent of CRP inclusion in the model (mediated effect WBC + CRP: β ± SE = 0.002 ± 0.001, P = 0.001).

CONCLUSIONS

These findings suggest that periodontitis is closely linked to hypertension and systemic inflammation is, in part, a mediator of this association.

Association Between Periodontitis and Blood Pressure Highlighted in Systemically Healthy Individuals: Results From a Nested Case-Control Study

[Figure: see text].

Implant failure and associated risk indicators: A retrospective study

OBJECTIVES

To evaluate early and late implant loss rates in a sample of patients who had received implant therapy in a university setting as well as patient- and implant-related variables for implant failure.

MATERIAL AND METHODS

This is a retrospective analysis in a cohort of patients who were treated with implant-supported restorative therapy during the period 2001-2012. Patients were randomly selected from an electronic database and scheduled for an appointment to record subject and implant characteristics. The primary study outcome was implant loss (i.e., early and late implant failure).

RESULTS

A total of 190 patients and 710 implants were included. The mean time in function was 8.2 (SD 2.4) years. Four implants (0.6%) failed in four patients (2.1%) prior to connection of the restoration within a mean period of 1.5 (SD 1.3) months after surgical procedure. Moreover, 17 subjects (8.9%) exhibited late implant failure, representing 26 implants (3.7%), after a mean follow-up of 5 years (SD 2.2) from prosthesis connection. The final multivariable model indicated three factors related to late implant failure: subjects <55 years (OR = 3.62; 95% CI 1.46-10.22; p = .002), smokers/former smokers (OR = 6.25; 95% CI 1.70-17.52; p = .005), and implants with no access to interproximal hygiene (OR = 7.25; 95% CI 2.20-28.25; p < .001).

CONCLUSIONS

The rate for early and late implant failure in a sample of 190 patients who had received implant therapy in a university setting was 2.1% and 8.9%, respectively, at subject level. Subjects <55 years and smokers/former smokers as well as implants with inadequate access to interproximal hygiene were significantly associated with late implant failure.

Keratinized tissue gain after free gingival graft augmentation procedures around teeth and dental implants: A prospective observational study

AIM

The primary goal was to compare the amount of keratinized tissue width (KTW) gain after free gingival graft (FGG) procedures around implants and teeth after 6 and 12 months of healing.

MATERIALS AND METHODS

Patients with mucogingival defects (<2 mm of KT) around teeth and implants underwent a gingival augmentation procedure by means of a FGG. Clinical measurements were performed with an individual stent to determine keratinized tissue width (KTW), length (KTL), graft shrinkage (GS) and gingival margin position (GMP) at 2 weeks, 6 weeks, 3 months, 6 months and 12 months after surgery.

RESULTS

Twenty-nine patients (35 sites) participated in this prospective study. After surgery, KTW decreased and GS increased significantly in both treatment groups during the whole follow-up period, but the biggest changes were observed at 6 weeks. When comparing both treatment groups, implant sites showed significantly more reduction in KTW and more GS. Thus, at 12 months, KTW and GS reduced 2.03 ± 2.1 mm and 36.74 ± 38.2% in the teeth group and 2.91 ± 12.03 mm and 61.8 ± 36.25% around implants, respectively.

CONCLUSIONS

A significantly greater reduction in KTW and more GS might be expected at implant sites.

Periodontitis is associated with hypertension: a systematic review and meta-analysis

Recent evidence suggests a link between periodontitis (PD) and hypertension, but the nature of this association remains unclear. The overall aim of this review was to critically appraise the evidence linking these two common disorders. Systematic search was conducted for studies published up to December 2018. Prevalence of hypertension in patients with PD (moderate/severe groups) vs. those without PD (non-PD) was the primary outcome. Additional outcomes included adjusted mean difference in systolic (SBP) and diastolic (DBP) blood pressure (BP) levels in PD vs. non-PD, assessment of biomarkers in PD and hypertension, and BP changes after periodontal therapy. From 81 studies selected, 40 were included in quantitative meta-analyses. Diagnoses of moderate-severe PD [odds ratio (OR) = 1.22; 95% confidence interval (CI): 1.10-1.35] and severe PD (OR = 1.49; 95% CI: 1.09-2.05) were associated with hypertension. Prospective studies confirmed PD diagnosis increased likelihood of hypertension occurrence (OR = 1.68; 95% CI: 0.85-3.35). Patients with PD exhibited higher mean SBP [weighted mean difference (WMD) of 4.49 mmHg; 95% CI: 2.88-6.11] and DBP (2.03 mmHg; 95% CI: 1.25-2.81) when compared with non-PD. Lastly, only 5 out of 12 interventional studies confirmed a reduction in BP following periodontal therapy, ranging from 3 to 12.5 mmHg of SBP and from 0 to 10 mmHg of DBP. PD is associated with increased odds of hypertension (SORT C) and higher SBP/DBP levels. The evidence suggesting that PD therapy could reduce BP is inconclusive. Although additional research is warranted on this association, these results suggest that oral health assessment and management of PD could not only improve oral/overall health and quality of life but also be of relevance in the management of patients with hypertension.

Dual-Center Cross-Sectional Analysis of Periodontal Stability Around Anterior All-Ceramic Crowns with a Feather-Edge or Chamfer Subgingival Preparation

Subgingival margins are often associated with adverse periodontal reactions, such as recession and gingival inflammation. The purpose of this cross-sectional dual-center study was to evaluate the periodontal health and stability of intrasulcular margins, comparing two prosthetic margin preparations: subgingival chamfer (SC) and subgingival feather-edge (SF) with gingival curettage. Ninety-six patients with 205 crowns (buccal margin 0.5 mm into the gingival sulcus) were included in the study. SF, gingival curettage, and intrasulcular restorative margin were prepared on 109 crowns; SC was prepared on 96. Restorations were in place for a mean of 55.9 months (range: 12 months to 10 years). No significant differences were found regarding probing depth between the two groups (mean buccal: 1.6 mm; mean interproximal: 2.3 mm). Significant increased recession was present around SCs, showing a higher margin-exposure frequency (buccal: 19.8% vs 3.7%; interproximal: 5.2% vs 1.4%). SC showed 8.5 times the risk of margin exposure compared to SF, men 5.5 times compared to women, and smokers 3.7 times compared to nonsmokers. Follow-up time was not a significant factor. SC sites showed a tendency for reduced buccal bleeding on probing compared to SF sites (3.0% vs 12.1%), but no significant difference was seen in a regression model. Plaque presence increased the risk of bleeding (4.1×), and women presented a higher risk of bleeding than men (3×). Subgingival margins can provide adequate periodontal health and stability if restorative procedures are well controlled and if patients are enrolled in an adequate maintenance program. SF with intrasulcular margin favors facial soft tissue stability, as reduced gingival recession was observed. The technique should be carefully applied to promote an adequate periodontal response.

Management of the extraction socket and timing of implant placement: Consensus report and clinical recommendations of group 3 of the XV European Workshop in Periodontology

BACKGROUND

The transition from a tooth requiring extraction to its replacement (with a dental implant) requires a series of clinical decisions related to timing, approach, materials, cost-effectiveness and the assessment of potential harm and patient preference. This workshop focused on the formulation of evidence-based consensus statements and clinical recommendations.

METHODS

Four systematic reviews covering the areas of alveolar ridge preservation/bone grafting, immediate early and delayed implant placement and alveolar bone augmentation at the time of implant placement in a healed ridge formed the basis of the deliberations. The level of evidence supporting each consensus statement and its strength was described using a modification of the GRADE tool.

RESULTS

The evidence base for each of the relevant topics was assessed and summarized in 23 consensus statements and 12 specific clinical recommendations. The group emphasized that the evidence base mostly relates to single tooth extraction/replacement; hence, external validity/applicability to multiple extractions requires careful consideration. The group identified six considerations that should assist clinicians in clinical decision-making: presence of infection, inability to achieve primary stability in the restoratively driven position, presence of a damaged alveolus, periodontal phenotype, aesthetic demands and systemic conditions.

CONCLUSIONS

A substantial and expanding evidence base is available to assist clinicians with clinical decision-making related to the transition from a tooth requiring extraction to its replacement with a dental implant. More high-quality research is needed for the development of evidence-based clinical guidelines.

Subepithelial Connective Tissue Graft in Combination with a Tunnel Technique for the Treatment of Miller Class II and III Gingival Recessions in Mandibular Incisors: Clinical and Esthetic Results

There is limited evidence regarding the effect of the subepithelial connective tissue graft (SCTG) on root coverage in the mandibular anterior region. A sample of 15 Miller Class II and III recessions were treated in 15 patients using a SCTG with a tunnel technique. After a mean follow-up of 20.53 months, the mean percentage of root coverage was 83.25% for all treated recessions. Furthermore, a statistically significant increase of keratinized tissue was observed at the end of the evaluation period (2.66 mm; P = .001). The combination of tunnel technique and SCTG should be considered a treatment option to obtain root coverage in mandibular incisors with Class II and III recession defects.

Radiographic and histological evaluation of deproteinized bovine bone mineral vs. deproteinized bovine bone mineral with 10% collagen in ridge preservation. A randomized controlled clinical trial

OBJECTIVES

The aims of this randomized clinical trial were to compare the dimensional changes and the histological composition after using deproteinized bovine bone mineral (DBBM) or deproteinized bovine bone mineral with 10% collagen (DBBM-C) and a collagen membrane in ridge preservation procedures.

MATERIAL AND METHODS

Patients who required an extraction and a subsequent implant-supported rehabilitation at a non-molar site were recruited. After extraction, a cone beam computed tomography (CBCT) was performed and sites were randomly treated either with DBBM or DBBM-C plus a collagen membrane. At 5 months, before implant placement, a second CBCT was performed and a biopsy of the area was obtained. A blinded investigator superimposed the CBCTs and performed measurements to determine bone volume changes between the two time points. Additionally, a histomorphometric analysis of the biopsies was performed in a blinded manner.

RESULTS

Eleven sites belonged to the DBBM group and eleven to the DBBM-C group. All together, a significant reduction in height and width was observed at 5 months of healing, but no statistically significant differences were observed between the DBBM and the DBBM-C group. The histomorphometric analysis revealed a similar composition in terms of newly formed bone, connective tissue and residual graft particles in both groups.

CONCLUSIONS

Deproteinized bovine bone mineral with 10% collagen showed a similar behaviour as DBBM not only in its capacity to minimize ridge contraction but also from a histological point of view. Thus, both graft materials seem to be suitable for ridge preservation procedures.

High prevalence of colonization of oral cavity by respiratory pathogens in frail older patients with oropharyngeal dysphagia

BACKGROUND

Aspiration pneumonia (AP) is caused by dysfunctional swallowing resulting in aspiration of material colonized by respiratory pathogens. The aim of this study was to assess and compare the swallowing physiology, health status, oral health status, and oral/nasal microbiota in frail older patients (FOP) with oropharyngeal dysphagia (OD) and a control group.

METHODS

We studied 47 FOP (>70 year) with OD by videofluoroscopy (17 with acute pneumonia -APN-, 15 with prior pneumonia-PNP- and 15 without) and 14 older controls without OD (H). Oral/nasal colonization by five respiratory pathogens was evaluated by qPCR, whereas commensal microbiota composition was assessed by pyrosequencing.

KEY RESULTS

(i) Frail older patients with OD presented similar comorbidities, poor functionality, polymedication, and prevalent videofluoroscopic signs of impaired safety of swallow (33.3-61.5%). However, patients with OD-APN also presented malnutrition, delayed laryngeal vestibule closure (409.23 ± 115.6 ms; p < 0.05), and silent aspirations (15.6%). (ii) Oral health was poor in all groups, 90% presented periodontitis and 72%, caries. (iii) Total bacterial load was similar in all groups, but higher in the oropharynx (>10(8) CFU/mL) than in the nose (<10(6) CFU/mL) (p < 0.0001). Colonization by respiratory pathogens was very high: 93% in OD patients (p < 0.05 vs H); 93% in OD-PNP (p < 0.05 vs H); 88% in OD-APN (p = 0.07 vs H), and lower in controls (67%).

CONCLUSIONS & INFERENCES

Frail older patients with OD had impaired health status, poor oral health, high oral bacterial load, and prevalence of oral colonization by respiratory pathogens and VFS signs of impaired safety of swallow, and were therefore at risk for contracting AP.

Inhibition of de novo plaque growth by a new 0.03 % chlorhexidine mouth rinse formulation applying a non-brushing model: a randomized, double blind clinical trial

OBJECTIVES

The aim of this study was to investigate the plaque inhibitory effect of a new 0.03 % chlorhexidine digluconate (CHX) and 0.05 % cetylpyridinium chloride (CPC) mouthrinse formulation and to explore patients' experience and side effects after its use.

MATERIALS AND METHODS

This short-term, randomized, double blind, parallel, clinical trial enrolled 150 periodontally healthy patients. These volunteers were randomly allocated to one of following mouthrinse groups (n = 50/group): 0.12 % CHX + 0.05 % CPC (Perio-Aid® Treatment alcohol-free), 0.03 % CHX + 0.05 % CPC new test formulation or to the placebo group. Clinical parameters (plaque, gingival, and stain indexes) and microbiological samples were taken at baseline, before supragingival cleaning, and after 4 days of undisturbed plaque growth, rinsing twice/day with one of the mouthrinses.

RESULTS

Plaque reduction was similar for the 0.12 % CHX (-0.52 ± 0.55) and 0.03 % CHX (-0.47 ± 0.49) groups. Both showed significant reductions in plaque accumulation compared to the placebo (p < 0.001). The new formulation had less of a negative impact on taste perception when compared to the 0.12 % CHX solution. The new CHX mouthrinse was also able to control bacterial loads and reduce some periodontopathogens.

CONCLUSIONS

This study indicated that the new 0.03 % CHX + 0.05 % CPC formulation exerted clinical efficacy similar to that achieved by an already-marketed 0.12 % CHX + 0.05 % CPC mouthrinse, but with slightly fewer side effects.

CLINICAL RELEVANCE

Lower CHX mouthrinse formulations could be effective in the inhibition of plaque regrowth with reduced unpleasant subjective side effects.

Evaluation of root coverage with and without connective tissue graft for the treatment of single maxillary gingival recession using an image analysis system: a randomized controlled clinical trial

The aim of this prospective randomized clinical study was to evaluate, by means of an image analysis system, the efficacy of two different surgical procedures for the treatment of Miller Class I and II maxillary gingival recession. Patients treated for maxillary gingival recession were recruited and randomly divided into two groups: patients who received a coronally advanced flap with connective tissue graft (CAF + CTG) or CAF alone. Outcome parameters included complete root coverage, recession reduction, and keratinized tissue amount. Twenty-five patients completed the 12-month follow-up period. Patients in the CAF + CTG group showed a better primary outcome- gingival recession at 12 months-than CAF patients (P = .0001). Gingival recession at 12 months had a median of 0.5 (interquartile range [IQR] 0.5 to 0.6) in the CAF + CTG group and a median of 1.0 (IQR 0.9 to 1.1) in the CAF group. CAF + CTG and CAF groups had similar complete root coverage at 6 and 12 months. Recession and keratinized tissue width significantly decreased over time (P < .0001), with no effect of treatment or of treatment over time. Buccal probing depth had similar values over time (P = .28) and in the two groups (P = .52). Buccal clinical attachment level had similar values in the two groups (P = .87); moreover, mesial and distal clinical attachment levels did not show any variation over time (P = .88 and P = .68, respectively). By means of a computerized image analysis system better outcomes in terms of recession reduction after 12 months of follow-up were measured for maxillary gingival recessions treated with CAF and CTG. Adjunctive application of a CTG under a CAF increased the probability of achieving complete root coverage in maxillary Miller Class I and II defects (61.5% versus 83.3%; P = .38). Both treatments were equally effective in providing a consistent reduction of the baseline recession.

Oral health in older patients with oropharyngeal dysphagia

BACKGROUND

oropharyngeal dysphagia (OD), aspiration and poor oral health status are potential risk factors in elderly patients with aspiration pneumonia (AP).

AIM

to assess the oral hygiene status and the prevalence of periodontal disease and dental caries in elderly patients with OD.

PATIENTS AND METHODS

fifty elderly patients (79.7 ± 6.64 years) with OD associated with ageing or neurological diseases and 15 elderly patients without OD (77.01 ± 4.51 years) were enrolled in this observational-transversal study. OD and aspiration were evaluated by videofluoroscopy (VFS). Oral health was assessed by: (i) the Simplified Oral Hygiene Index (OHI-S); (ii) a complete periodontal examination, assessing the periodontal pocket depth, clinical attachment loss and bleeding on probing to study periodontal diseases (periodontitis, gingivitis); and (iii) the presence of dental caries.

RESULTS

8/50 elderly patients with OD presented VFS signs of aspiration, half of them silent; 40/50, signs of penetration into laryngeal vestibule and 16/50, oropharyngeal residue. Prevalence of edentulism and caries was higher in patients with OD. Dentate older patients with OD (30/50) presented the following complications (i) poor oral hygiene in 18 patients (OHI-S 3.1-6), (ii) gingivitis in 2 and periodontitis in 28 and (iii) caries in 16.

CONCLUSIONS

older patients with OD presented polymorbidity and impaired health status, high prevalence of VFS signs of impaired safety of swallow and poor oral health status with high prevalence of periodontal diseases and caries. These patients are at great risk of developing AP. We recommend a policy of systematic oral health assessment in elderly patients with OD.

High-density polytetrafluoroethylene membranes in guided bone and tissue regeneration procedures: a literature review

Expanded polytetrafluoroethylene (e-PTFE) has been used successfully as a membrane barrier for regeneration procedures. However, when exposed to the oral cavity, its high porosity increases the risk of early infection, which can affect surgical outcomes. An alternative to e-PTFE is non-expanded and dense polytetrafluoroethylene (n-PFTE), which results in lower levels of early infection following surgical procedures. The aim of this literature review was to analyze and describe the available literature on n-PFTE, report the indications for use, advantages, disadvantages, surgical protocols, and complications. The medical databases Medline-PubMed and Cochrane Library were searched and supplemented with a hand search for reports published between 1980 and May 2012 on n-PTFE membranes. The search strategy was limited to animal, human, and in vitro studies in dental journals published in English. Twenty-four articles that analyzed the use of n-PTFE as a barrier membrane for guided tissue regeneration and guided bone regeneration around teeth and implants were identified: two in vitro studies, seven experimental studies, and 15 clinical studies. There is limited clinical and histological evidence for the use of n-PTFE membranes at present, with some indications in guided tissue regeneration and guided bone regeneration in immediate implants and fresh extraction sockets.

Clinical changes in periodontal subjects with the probiotic Lactobacillus reuteri Prodentis: a preliminary randomized clinical trial

OBJECTIVES

The aim of this study was to assess the clinical effect of the administration of Lactobacillus reuteri Prodentis as a probiotic agent in the treatment of initial to moderate chronic periodontitis. Secondary objectives were to evaluate the patient 'compliance' factor and to observe the potential side-effects of the probiotic agent.

MATERIALS AND METHODS

Twenty systemically healthy, non-smoking subjects with initial-to-moderate chronic periodontitis were enrolled in this 1-month double-blind, placebo-controlled, randomized clinical trial. Subjects were randomly assigned to receive tablets containing Lactobacillus reuteri Prodentis or placebo once a day for 30 days. Clinical parameters were collected at baseline and 30 days post-treatment.

RESULTS

Periodontal clinical parameters were improved in the test group after a 30-day intervention. The test group demonstrated a statistically significant reduction (p < 0.05) in all the periodontal parameters included in the study (plaque index, bleeding on probing and pocket probing depths), while the control group treated with placebo did not show any statistically significant change in periodontal parameters.

CONCLUSIONS

These data indicate that oral administration of Lactobacillus reuteri Prodentis improved the short-term clinical outcomes in non-smoking patients with initial-to-moderate chronic periodontitis.

Prospective evaluation of the use of motorized ridge expanders in guided bone regeneration for future implant sites

The purposes of this prospective, randomized, controlled clinical investigation were to evaluate the performance of motorized ridge expanders (MREs) and to compare their results with those achieved using lateral ridge augmentation (LRA). Eight subjects with bilateral ridge deformities were selected. One technique was used on the right side and the other on the left. Implants were placed 6 months after bone augmentation procedures. All measurements were recorded at 2 and 5 mm from the most coronal aspect of the crest. The augmentation achieved with both techniques was statistically significant: 1.2 mm for LRA and 1.5 mm for MRE 2 mm from the crest and 1.5 mm for LRA and 1.6 mm for MRE at 5 mm from the crest. The differences between the two techniques were statistically insignificant. The amount of expansion achieved in the MRE sites appeared to be negatively correlated with the thickness of the cancellous bone (P < .05), and it was not affected by the thickness of the cortical plate. The MRE technique appears to be as effective as the LRA technique in augmenting the thickness of atrophic ridges. Defects treated with MREs showed less bone width contraction during the first 6 months of healing.

Creeping attachment after 10 years of treatment of a gingival recession with acellular dermal matrix: a case report

Acellular dermal matrix grafts have become a good alternative to autogenous soft tissue grafts in root coverage. Until now, the literature has reported short- or medium-term data regarding the stability of the gingival margin after the use of acellular dermal matrix on root coverage. The aim of this article is to describe a case report with 10 years of evolution with creeping attachment that developed bucally on a moderate recession of a maxillary canine with an old composite restoration subsequent to an acellular dermal matrix. Long-term creeping attachment and complete root coverage on a restored tooth treated with acellular dermal matrix has not been previously reported in the dental literature.