Salivary lipid changes in young adult tobacco smokers and e-cigarette users: a hidden risk to oral health?

STUDY DESIGN

A cross-sectional, age- and gender-matched study was conducted to investigate the effects of different forms of nicotine delivery on salivary lipid profiles among young adult novice smokers compared to non-smokers.

OBJECTIVE

To assess the effect of smoking traditional cigarettes, e-cigarettes, and heated tobacco products (HTPs) on the levels of specific sphingolipids (sphingosine, sphinganine, and sphingosine-1-phosphate), various ceramides, and lipid peroxidation products [malondialdehyde (MDA) and 4-hydroxynonenal (4-HNE)] in both unstimulated and stimulated saliva samples collected from healthy young adults who had been smoking for 1-3 years and used only 1 of the 3 nicotine delivering methods.

METHODS

Selection criteria included healthy young adults under 30 years old, with normal BMI and typical diet composition, and with no oral inflammatory lesions, orthodontic/dental appliances, or recent intake of medications or supplements. A total of 75 smokers and 25 non-smokers were enrolled in the study. Smokers were categorized into three groups, each comprising 25 individuals: traditional cigarette smokers, e-cigarette users, and HTPs smokers. Saliva samples were collected and analyzed for sphingolipid concentrations using ultra-high-performance liquid chromatography-tandem mass spectrometry. The concentrations of MDA and 4-HNE were measured using colorimetric and ELISA assays, respectively.

RESULTS

The average smoking intensity in the traditional cigarette group was 10 cigarettes per day. Salivary sphingolipid and ceramides concentrations were significantly lower in smokers compared to non-smokers across all nicotine delivery methods (p < 0.0001). Moreover, traditional cigarette smokers exhibited higher levels of 4-HNE and MDA in both stimulated and unstimulated saliva, compared to non-smokers (p < 0.01). In stimulated saliva, both MDA and 4-HNE in e-cigarette users, and MDA in HTPs users, showed significantly lower concentrations than their comparators in traditional cigarette smokers (p < 0.01).

CONCLUSION

Different nicotine delivery methods impact salivary lipid profile during the initial period of smoking habit. Reduced sphingolipids and elevated lipid peroxidation products suggest a disturbed lipid balance in the oral cavity due to enhanced oxidative stress within the salivary glands of novice smokers.

CEMENTED AND SCREW-RETAINED IMPLANT-SUPPORTED RESTORATIONS MAY HAVE A COMPARABLE RISK FOR PERI-IMPLANT MUCOSITIS AND PERI-IMPLANTITIS

ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION

Reis INRD, Fukuoka GL, Nagay BE, Pannuti CM, Spin-Neto R, Silva EVFD. Incidence of peri-implant disease associated with cement- and screw-retained implant-supported prostheses: A systematic review and meta-analysis. J Prosthet Dent. 2023 Oct 2:S0022-3913(23)00563-2. doi:10.1016/j.prosdent.2023.08.030. Epub ahead of print. PMID: 37793953.

SOURCE OF FUNDING

None declared.

TYPE OF STUDY/DESIGN

Systematic review and meta-analysis.

Does flapless immediate implant placement lead to significant preservation of buccal bone compared to flap surgical protocol?

DESIGN

A systematic review and meta-analysis of randomized clinical trials.

DATA SOURCES

The electronic search included Pubmed, Web of Science, Embase, and Cochrane databases up to June 2022. Cross-referencing, searching for gray literature at ( www.

CLINICALTRIALS

gov ), and hand searching of seven relevant journals were also performed.

SELECTION CRITERIA

Inclusion criteria consisted of: randomized clinical trials (RCTs) published in English comparing flapless to flap surgery for IIP using single titanium implants in the esthetic zone of healthy ≥18 years old patients. Prospective and retrospective case series, cross-sectional studies, letters to editors and reviews were excluded. The key study factor was to assess the impact of the surgical approach (flap versus flapless surgery) on buccal hard and soft tissue changes after single immediate implants for the anterior teeth in healthy adult patients. The primary outcome was horizontal buccal bone change (HBBC), measured by CBCT. Secondary outcomes were implant survival, vertical buccal bone change, postoperative pain, and clinical and esthetic parameters.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers conducted both electronic and manual searches for eligible clinical studies. The evaluation was carried out at the title level followed by the abstract level, and the full texts of the qualified articles were then examined. Any disagreements were resolved by discussion with a third reviewer. Quality assessment of the included RCTs was conducted by two additional reviewers who were not part in the search process using the revised Cochrane risk-of-bias tool for randomized trials (RoB 2). A meta-analysis was conducted on outcome variables that were documented in three or more articles.

RESULTS

Five RCTs fully met the selection criteria for the final qualitative analysis comprising data of 140 patients who received 140 single immediate implants (flapless: 68; flap:72) with a mean age ranging from 30 to 67 years. Follow-up extended for 6-12 months. Two RCTs showed an overall low risk of bias, whereas the other three RCTs had an overall high risk, basically due to using inappropriate methods of outcome measurements. Meta-analysis included three RCTs and revealed a mean difference of 0.48 mm (95% CI [0.13,0.84], p = 0.007) in HBBC between surgical approaches, favoring flapless surgery. Heterogeneity among the studies was low (I2 = 29%; p = 0.250). For implant survival, however, meta-analysis failed to find a significant difference among the groups (RR 1.00, 95% CI [0.93, 1.07], p = 0.920). Due to limited data, meta-analyses could not be conducted for other secondary outcomes. Available studies consistently showed a favorable effect of flapless surgery in terms of vertical buccal bone change and pain, while only one study assessed the vertical midfacial soft tissue change, and no data were reported on esthetic outcomes.

CONCLUSION

According to CBCT data, flapless IIP resulted in greater preservation of buccal bone as compared to flap IIP. However, the clinical significance of this finding remains uncertain since clinical and esthetic outcomes were insufficiently reported.

Mind games in dentistry: confounded evidence suggests a substantial nocebo response in dental impaction pain model

DESIGN

A systematic review and metaanalysis of randomized clinical trials (RCTs).

DATA SOURCES

Electronic search was conducted in PubMed, Embase, Scopus, Web of Science and the Cochrane Central Register of Controlled Trials (CENTRAL), on 22 May 2021.

SELECTION CRITERIA

Eligibility criteria included parallel-group placebo-controlled RCTs assessing analgesics after third molar (M3) surgery in healthy patients, reporting the number of patients with at least one drug-related adverse event (AE), and being published in English.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently screened all identified articles against the eligibility criteria, and performed quality assessment and data extraction. Any disagreements were resolved by discussion involving a third reviewer. The primary outcome was the pooled rate of drug-related AEs in placebo and active arms of RCTs assessing analgesic treatment following M3 surgery. Secondary outcome was the drug-related dropout rates in the same setting.

RESULTS

A total of 50 RCTs in 47 articles were included in the analyses. The pooled rates of patients with AE ≥ 1 in the placebo and active arms were 22.8% and 20.6%, respectively. The pooled drug-related dropout rates in the placebo and active arms were 0.24% and 0.08%, respectively. There were no significant risk differences in patients with AE ≥ 1 and drug-related dropouts (p = 0.61 and p = 0.94; respectively). High statistical heterogeneity was found for the proportion of patients with AE ≥ 1 (I2 = 79.7%, p < 0.001), but not for drug-related dropout rates (I2 = 0%, p = 1.00).

CONCLUSION

Patients in the placebo arm reported AEs at a similar frequency as patients receiving active treatment, suggesting that most analgesic-related AEs after M3 surgery may be attributed to the nocebo phenomenon.

Dose- and time-dependent association of smoking and its cessation with risk of peri-implant diseases

DESIGN

A retrospective cohort study involved patients who received at least one implant-supported restoration at a university dental clinic between 2001 and 2013. Patients were randomly selected from an electronic database, and their recruitment via telephone contact spanned from February 2021 until July 2021.

MAIN OBJECTIVE

To investigate the association of smoking and its cessation with the risk of peri-implant mucositis and peri-implantitis in a cohort of implant-treated patients.

METHODS

The study adhered to the principles outlined in the Declaration of Helsinki and followed the STROBE guidelines for reporting observational research. Included were adult patients who were rehabilitated with dental implants, irrespective of the type of edentulism, superstructure, and prosthetic retention, provided that they had adequate access for peri-implant probing. Patients with incomplete records were excluded. Clinical measurements included plaque and bleeding indices, periodontal pocket depth, suppuration on probing, mucosal recession, and width of keratinized mucosa. Periapical radiographs were taken and marginal bone level (MBL) was measured using ImageJ software. The primary outcome variable was peri-implant status which was classified into: health (H), peri-implant mucositis (PM), and peri-implantitis (PI). Smoking status was categorized into: never-smokers, former smokers, and current smokers. Smoking information included: daily cigarette consumption, duration of smoking (in years), and age at initiation, and for former smokers, the duration of smoking cessation.

RESULTS

The cohort included 117 patients (55 females and 62 males) with a mean age of 64.2 years at examination. They were rehabilitated by 450 implants, with an average of 4.6 implants per patient and a mean duration of 8 years in function. Out of the total, 39 patients were H, while 41 and 37 showed PM and PI, respectively. Periodontal and MBL measures were significantly higher in PM and PI groups compared to H group (p < 0.001). Considering tobacco use, 56 patients were never-smokers, 42 former smokers, and 19 current smokers. The average daily consumption of cigarettes was 15.7. Ever-smokers >23 pack-years had a significantly higher risk for PI (OR = 3.40; 95% CI 0.91-17.30; p = 0.002) compared to nonsmokers. Regression analysis showed that subjects with a span since smoking cessation of more than 21 years exhibited a significantly lower risk of peri-implant diseases (PIDs) than those who had ceased smoking within 21 years (p = 0.028).

CONCLUSION

A smoking intensity exceeding 23 pack-years was significantly associated with PI risk, while the risk of PIDs was comparable between never-smokers and those who had quit smoking more than 21 years ago.

How far does feedback on oral malodor assessment influence the decision to quit smoking?

DESIGN

A retrospective, uncontrolled, questionnaire-based, pre-post study involving adult male smoker volunteers who were invited to attend a one-day smoking cessation event at their workplace.

OBJECTIVE

To assess the effect of feedback on motivation for smoking cessation using oral-malodor measurements.

METHODS

At baseline, the participants attended a brief video presentation regarding various oral health-specific effects of smoking, joined a group introduction to smoking-cessation aids, and were given questionnaires that inquired information about smoking status including type, daily consumption, and duration. Subsequently, respiratory function and oral-malodor assessment were conducted using exhaled and oral cavity air, respectively. To measure oral-malodor, hydrogen sulfide, methyl mercaptan, and dimethyl sulfide concentrations were determined. Participants' intention for smoking cessation was evaluated through questionnaire before and after the event, classifying their intentions as aiming to quit within the next month, within the next 6 months, or having no intention to quit smoking. Immediate feedback on respiratory function and oral malodor measurements was provided by medical and dental blinded examiners, respectively.

RESULTS

A total of 241 men, aged 20-54 years, were enrolled and included: 169 (70.1%) exclusive cigarette smokers, 39 (16.2%) exclusive heated-tobacco product users, and 33 (13.7%) users of both. Prior to the health event, 8.7%, 17.0%, and 74.3% of smokers expressed intentions to quit within the next month, the next 6 months, or had no intention to quit, respectively. After the event, the corresponding percentages shifted to 17.8%, 26.6%, and 55.6%. In multivariable logistic regression analysis, the association with intention to quit in the next month was significant only for methyl mercaptan concentration in oral cavity air, with an adjusted odds ratio (AOR) of 4.24 (95% CI: 1.52-11.84; p = 0.006). Sensitivity analysis revealed that this association was concentration-dependent. On the other hand, higher daily tobacco consumption (≥ 15 pieces) was significantly associated with less likely intention to quit in the next 6 months (AOR = 0.37; 95% CI: 0.15-0.92, p = 0.032).

CONCLUSION

Feedback on oral malodor measurement may support the motivation of men to quit smoking within the next month, rather than waiting for the next 6 months.

Preliminary evidence of impaired oral wound healing in e-cigarette users: a call for perioperative vaping cessation

DESIGN

A prospective, parallel-arm, age- and gender-matched clinical study.

OBJECTIVE

To assess and compare palatal wound healing of orally and systemically healthy e-cigarette users with a matched group of non-vapers.

METHODS

Included were healthy adult volunteers (18-50 years), either e-cigarette users or never smokers, who agreed to use a study-specific e-cigarette device and e-liquids, and were willing to provide consent from. Exclusion criteria were: hypersensitivity to lidocaine, ASA grade >2, recent antibiotic therapy, history of periodontal surgery, active oral lesions, and carious cavities. E-cigarette users were instructed to use the device 2 times daily for more than 1 hour each, with 20 puffs per session. Bilateral 5 mm punch biopsy wounds were made palatally opposite to the 2nd premolar, and subjects were followed up at 1, 2, 4, 7, 14 and 21 days post-operatively. Throughout this period, 3 mm punch biopsies were harvested from the right and left healing wounds at 1- and 3- weeks respectively. All surgical procedures were conducted by the same operator. Pre-wounding palatal biofilms were collected by swabs for metabolomic profiling. Wound healing was evaluated by clinical assessment, metabolite profile, histology, and immunohistochemistry to quantify the following proteins: vimentin, keratin and filaggrin.

RESULTS

A total of 16 individuals were recruited: 8 e-cigarette users and 8 non-vapers. The average age was 27 years, and there were 4 men and 4 women in each group. The e-cigarette group tended to show a slightly lower total score of healing index in all visits compared to the control subjects, but the differences were not statistically significant. No site exhibited suppuration at any point, and no differences between groups were observed in the parameters of granulation. However, statistically significant differences were observed between groups for bleeding and swelling (p < 0.0001 and p = 0.0083, respectively), but not for epithelialization and redness (p = 0.0834 and p = 0.0967, respectively). Pain on palpation and difficulty in achieving hemostasis were more prevalent in e-cigarette group. The metabolic analysis between week 1 and 3 revealed significantly elevated carbohydrate and lipid metabolism in e-cigarette users, while protein metabolism was over-represented in the control group. For immunohistochemistry, significantly lower scores of vimentin, keratin, and filaggrin were shown in the e-cigarette group compared to controls at 1 and 3 weeks (p < 0.05 and p < 0.01, respectively).

CONCLUSION

E-cigarettes may significantly impair oral wound healing by impacting keratinization of epithelium and modifying the metabolic composition of the oral microbiome. Therefore, vaping cannot be regarded as safe for patients undergoing oral surgery.

FOR IMMEDIATE IMPLANT PLACEMENT, SOCKET SHIELD TECHNIQUE MAY SIGNIFICANTLY REDUCE MARGINAL BONE LOSS AS COMPARED TO CONVENTIONAL PROTOCOL

ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION

Clinical outcomes of retention of the buccal root section combined with immediate implant placement: A systematic review of longitudinal studies. Kotsakis GA, Nguyen TT, Siormpas K, Pikos MA, Pohl S, Tarnow D, Mitsias M, Root Membrane Group. Clin Implant Dent Relat Res. 2023; 25(1): 23-34. doi:10.1111/cid.13150. Epub 2022 Nov 4. PMID: 36,331,494.

SOURCE OF FUNDING

The study was self-funded by the authors.

TYPE OF STUDY/DESIGN

Systematic review and meta-analysis.

Further evidence confirms the association between smoking and dry socket: a motivational opportunity for tobacco cessation

DESIGN

A systematic review and meta-analysis of observational studies.

DATA SOURCES

Electronic search included PubMed, Scopus, and Web of Science databases up to March 2022 using appropriate keywords.

SELECTION CRITERIA

The review included all observational studies (case-control, cohort and cross-sectional studies) published in English after 2000, comparing the prevalence of dry socket between smokers and non-smokers after simple or surgical tooth extraction. Exclusion criteria included patients with other post-extraction complications, prevalence of different risk factors, and unrelated study designs (literature reviews, case reports, expert opinion, and conference reports).

DATA EXTRACTION AND SYNTHESIS

Two independent investigators screened the records (by title, abstract, and full text), and selected the eligible studies according to the predefined criteria. Collected data from each study included author name and country, year of publication, gender and age of patients, smoking status, inclusion and exclusion criteria, medical history and oral hygiene, prevalence of dry socket, type of tooth and extraction technique, symptoms and treatment. Risk of bias was assessed according to the (NHLBI, NIH) Quality Assessment Tool For Observational Cohort and Cross-Sectional Studies, while the level of evidence was assessed using the classification of the Oxford Centre for Evidence-Based Medicine levels for diagnosis. Two independent reviewers conducted the assessments, and any disagreements were addressed through discussion.

RESULTS

Eleven studies from ten different countries representing a total of 10,195 patients (3007 smokers and 7188 non-smokers) were included in the final analysis. Nine studies were classified as having "good" quality and two as "intermediate," while all of the studies have the third or fourth level of evidence (through 5-graded scale). The prevalence of dry socket in smokers was about 13.2% (95% CI: 5.8-23.1%) and in non-smokers about 3.8% (95% CI: 2.1-6.0%). Meta-analysis showed that regular tobacco smoking was associated a more than 3-fold increase in the odds of dry socket after tooth extraction.

CONCLUSION

Despite heterogeneity among the included studies (different age groups and types of teeth extracted), there was a consistent association between cigarette smoking and an elevated risk of developing dry socket post tooth extraction.

Dose-response association of smoking with delayed healing of apical periodontitis after endodontic treatment

DESIGN

A prospective cohort study aimed to assess the inhibitory effect of cigarette smoking on the rate of periapical bone healing after root canal treatment (RCT). Examination included both clinical and radiographic parameters to define healing status at baseline, 6 months, and 1 year after RCT.

OBJECTIVES

To examine and compare the healing rate of apical periodontitis (AP) after RCT between smokers and nonsmokers, and to evaluate how the intensity and duration of smoking affect AP healing up to 1-year follow-up. Study hypothesis was that smoking habits could delay or deteriorate AP healing.

METHODS

The study protocol was approved by the local ethics committee and all of the participants signed a consent form. Included were adult patients with a radiographically confirmed AP in a single tooth with a favorable periodontal prognosis and adequate coronal restoration, with no previous RCT. Excluded patients were those diagnosed with a systemic disease or on medications affecting bone metabolism, former and occasional smokers, pregnant patients, and those who refused to participate. Smokers were defined as those who consumed at least 100 cigarettes in their lifetime and currently smoke. Smoking intensity was classified according to cigarette consumption per day (CPD) into: heavy smoking (≥20 CPD) and mild smoking (˂20 CPD). Tobacco exposure over time was assessed by smoking index (=CPD ˟ duration of tobacco smoking in years) and categorized into: nonsmoker, <400, 400-799, and ≥800. The control group included healthy nonsmokers and matched the smoker group in terms of age and gender. All RCTs were performed by endodontic specialists following a standardized protocol. Clinical examination involved percussion and palpation tests, periodontal probing and examination of the coronal restoration; while the periapical healing was radiographically assessed using the periapical index (PAI) scoring.

RESULTS

A total of 110 patients (55 smokers and 55 nonsmokers) were included. The two groups were comparable regarding age, gender, tooth type, socioeconomics, and periapical index scores at the baseline. The mean CPD among smokers was 12.22, and most of them were "mild smokers". At 12-month follow-up, nonsmokers showed a significantly higher healing rate compared to smokers (90.9% vs. 58.2%; χ2 = 13.846; p < 0.001). Conversely, smokers had significantly higher PAI when compared to the control group (p = 0.024). Regression analysis demonstrated that the risk of AP persistence increases with an increase in the smoking index [OR = 7.66; 95% CI: 2.51-23.28; p < 0.001, for smoking index <400 and (OR = 9.65; 95% CI: 1.45-64.14; p = 0.019, for smoking index 400-799].

CONCLUSION

Smoking was significantly associated with delayed AP healing after RCT. The likelihood of AP persistence rises as smoking exposure increases. These results could impact clinical decisions and guidelines concerning smokers.

Articaine improves anesthetic achievement for exodontia performed by undergraduate dental students: A clinical comparative study

PURPOSE/OBJECTIVES

To assess the clinical performance of undergraduate dental students in delivering inferior alveolar nerve block (IANB) with either articaine or lidocaine, and to compare the success rate of their IANBs between articaine and lidocaine for the extraction of mandibular molar teeth.

METHODS

In this clinical trial, patients were randomly distributed into 2 study groups: articaine and lidocaine groups. In each group, dental students performed IANB followed by forceps extraction of 1 mandibular molar under close supervision. The operative parameters measured included: assessment of anesthetic technique (on 10 points visual analogue scale 'VAS-10'), onset and depth of anesthesia, intra-operative pain perceived by patients and their satisfaction level (on VAS-10), and the success rate of IANB (in terms of need to additional anesthesia). Data analyses used were descriptive statistics, t-test, χ² test, and Pearson's correlation.

RESULTS

One-hundred sixty patients were included in the final analysis, 80 in each group. The overall students' IANB technique was assessed as good (mean score 7.3). Articaine group showed significantly higher success rate of IANB (71%) compared to (55%) in lidocaine group, (P = 0.03). Patients also reported significantly higher satisfaction scores in the articaine group (P = 0.04). There were no significant difference in the onset of action and intra-operative pain level between the 2 groups.

CONCLUSIONS

Students' IANBs were generally assessed as "good." Articaine IANBs performed by undergraduate students showed significantly higher success rate than lidocaine IANBs. By using articaine, the anesthetic achievement was greater for mandibular molar extraction performed by undergraduate students.

Submucosal dexamethasone injection improves quality of life measures after third molar surgery: a comparative study

PURPOSE

The purpose of the present study was to compare the effect of submucosal versus intramuscular administration of dexamethasone sodium phosphate on patients' quality of life after surgical removal of impacted lower third molars.

PATIENTS AND METHODS

A randomized, non-blind, clinical trial was planned. The sample was composed of patients requiring extraction under local anesthesia of a single partial bony impacted mandibular third molar with Class II or III and position B or C, according to the Pell and Gregory classification. The patients were randomly distributed into 1 of 3 groups: submucosal dexamethasone, intramuscular dexamethasone, and a control group that received no steroid. A modified translated questionnaire was used to assess the patients' perception regarding different quality of life dimensions. In addition, the objective measurements of facial pain, swelling, and trismus were performed on days 1, 3, and 7 postoperatively.

RESULTS

A total of 33 subjects requiring surgical removal of a single impacted mandibular third molar under local anesthesia were included in the present study. Both dexamethasone groups showed a significant reduction in swelling and pain compared with the control group at all intervals (P < .05). Submucosal dexamethasone provided significant improvement in trismus compared with the control group on day 1 postoperatively (P = .026). Both dexamethasone groups showed a highly significant difference in the effect on quality of life and the duration of effect in all subscale scores (P < .01) except for the "speech" and "appearance" subscales. The effect was comparable between the 2 treated groups in all parameters. The effect of the 2 routes of dexamethasone was also comparable for all parameters.

CONCLUSIONS

Submucosal injection of dexamethasone 4 mg is an effective therapeutic strategy for improving the quality of life after surgical removal of impacted lower third molars with a comparable effect on postoperative sequelae to intramuscular injection. It offers a simple, safe, painless, noninvasive, and cost effective therapeutic option for moderate and severe cases.