April 28, 2017
Floss and peri-implantitis risk
A clinical report published in the May 2016 issue of Clinical Oral Implants Research indicates that dental floss or superfloss may not be suitable for interproximal cleaning of dental implant restorations if roughened implant surfaces are exposed.
The article, first published online August 11, 2015, discusses potential complications from floss use if there are exposed roughened implant surfaces even with “intensive oral hygiene regime practices.”
The report findings are based on observational study of 10 patients at Rijnland Hospital in Leiderdorp, the Netherlands, who had persistent peri-implantitis—tissue inflammation including bone loss.
The 10 cases emerged from a recall system rigidly used for patients who received dental implant treatment at the hospital. Under regular monitoring by a dental hygienist, all patients were provided detailed postoperative instructions for “optimal peri-implant plaque removal.” The oral hygiene practice regimen also was tailored to the particular needs of each patient, depending on the superstructures completed and patient compliance.
Assessments and notations were made of plaque and bleeding indexes, peri-implant tissues were evaluated based on probing depth measurements, and peri-implant bone levels were determined through radiograph or periapical radiographs obtained every 2 years. Specific measures were taken when peri-implant mucositis or peri-implantitis occurred.
When researchers found either peri-implant mucositis (bleeding on probing or suppuration, but no bone loss) or peri-implantitis, they performed extensive professional supramucosal and submucosal cleaning and evaluated and changed, if necessary, the oral hygiene regimen. When researchers found peri-implantitis, they obtained a microbiological culture sample to check for pathogens.
Patients who did not achieve healthy peri-implant conditions were scheduled for exploratory surgery, per the protocol of cumulative interceptive supportive therapy (CIST). In the CIST process, a mucoperiosteal flap is raised to inspect and meticulously clean the bone and the implant neck. Other prophylactic CIST measures include treating the exposed rough dental implant surface with an acid etching gel, 1% iodine solution, and 3% hydrogen peroxide, as well as filling possible local bony defects with autologous bone.
Despite the application of the CIST protocol, 10 patients with persistent peri-implantitis emerged and were further treated through exploratory surgery. “All ten patients revealed the presence of remnants of dental floss around the rough part of the dental implants" and “a significant increase of predominately Fusobacterium nucleatum species” was detected, wrote the researchers.
Nine of the 10 patients experienced “significant improvement in the peri-implant condition” after the exploratory surgery and full debridement of the peri-implant sites.
The researchers concluded that, if the roughened implant surface is exposed, “the application of dental floss in daily oral hygiene practices in patients with dental implants may represent a risk for peri-implant disease progression owing to the fact that dental floss may be torn and trapped in the peri-implant sulcus.
“The use of interdental brushes or wooden toothpicks in situations with exposed rough dental implant surfaces is certainly to be preferred,” they wrote.
Read the original article.
Consulting Editor: Donald A. Curtis, DMD, FACP
Diplomate, American Board of Prosthodontics
Professor, University of California San Francisco
Proton pump inhibitors and implant failure
Findings of a Canadian study published in the April issue of Clinical Implant Dentistry and Related Research suggest that use of proton pump inhibitors (PPIs) may increase risk of osseointegrated dental implant failure.
The study’s authors, dentistry faculty members at McGill University in Montreal, Quebec, Canada, described the study, first published online October 20, 2016, as a "large retrospective Canadian cohort" and declared "within the limit of our knowledge, this is the first study reporting the association between PPIs treatment and the risk of osseointegrated dental implant failure." As such, they maintain, there was no other study found in the dental literature for comparison.
As a group of drugs, PPIs are, per the article, “very effective in both prevention and treatment of gastrointestinal acid-related conditions, such as peptic ulcer, gastroesophageal reflux disease (GERD or GORD), dyspepsia, helicobacter pylori infections, eosinophilic esophagitis, gastrinomas, and stress gastritis.” The drugs, the authors says, are rapidly becoming the third most prescribed pharmaceutical products worldwide.
However, PPIs are a known inhibitor of bone formation. The U.S. Food and Drug Administration (FDA), according to the authors, has acknowledged a relationship between PPIs use and bone metabolism. The drugs “suppress gastric acidity by inhibiting the functions of the proton pump (H+/K+ ATPase), which can also be found in bones. The proton pump inhibition of the osteoclasts can decrease their activities. … PPIs decrease bone mineral density (BMD) by affecting calcium homeostasis and impairing calcium absorption.”
The study patients received dental implants at East Coast Oral Surgery in Moncton, New Brunswick, Canada, as an open cohort followed for 8 and a half years, from January 2007 to September 2015. The cohort included 799 patients with a total of 1,773 osseointegrated dental implants—133 implants in 58 PPI users and 1,640 in 741 nonusers. Of the 799 patients, 430 were women and 369 were men, ranging in age from 18 through 93 years.
At the study’s end, patients using PPIs had higher risk of implant failure than did nonusers—6.8% for people using PPIs compared with 3.2% for nonusers.
Patients who had at least 1 of the following complications were considered to have a failed implant: pain on function, mobility, radiographic bone loss equivalent to one-half of the implant length, uncontrolled exudate, and implant no longer in mouth.
Acknowledging the limits of their study and forecasting the need for confirmatory and mechanistic studies to confirm results, the authors remarked that their observation revealed an association between PPIs usage and a higher risk of experiencing osseointegrated implants failure. They surmised that the information reflected in the study may help prevent osseointegrated dental implant complications caused by PPIs.
“This study could be a steppingstone towards the development of guidelines for patients who need implant therapy and are taking systemic medications, such as PPIs,” wrote the authors. “According to the results, this group of patients should undergo careful skeletal evaluations and surgical treatment planning prior to implant intervention. This study suggests that patients taking PPIs who need dental implants placement, need to be managed carefully, especially when they are [exposed] to additional risk factors, such as NSAIDs [nonsteroidal anti-inflammatory drugs] usage, smoking and low baseline calcium intake.”
Read the original article.
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Outcomes with computer-engineered complete dentures
A systematic review of the dental literature pointed to a positive trend in outcomes relative to computer-engineered complete dentures (CECD).
The study authors, who published their findings in the April issue of The Journal of Prosthetic Dentistry, had determined that a growing proliferation of articles existed on computer-aided denture manufacturing of complete dentures (CDs) but with sparse assessments of clinical outcomes. “This area of removable prosthodontics continues to evolve with the introduction of these newer products, but little information is available on their clinical outcomes” they said.
CECD refers to either digital or computer-aided design and computer-aided manufacturing, said the authors when describing what they found in the dental literature.
Using a patient population, intervention, comparison, and outcome (PICO) framework, the authors constructed an appropriate search strategy, defined inclusion and exclusion criteria, retrieved and selected studies, extracted suitable data, and constructed tables summarizing results. Their PICO questions were:
• What are the clinical outcomes with CECD?
• Are there specific applications and significant advantages for CECD?
Included articles were published in English from January 1984 through May 2016 and met the criteria of being comparative or noncomparative, prospective or retrospective, longitudinal clinical studies and clinical reports and techniques articles related to clinical outcomes with CECDs. Excluded articles were outside of this set of criteria, failed to meet the threshold of a minimum of 5 participants for assessing clinical outcomes, or did not discuss specific applications and advantages.
Ultimately, the authors’ article-sorting process yielded 37 relevant articles: 4 that assessed clinical outcomes, 10 that reported unique clinical applications with CECDs, and 23 others related to the topic.
The authors wrote that “The primary purpose of this systematic review was to study clinical outcomes and applications with CECDs. Initially, 37 articles were selected from the electronic search. After review, only 4 articles were retained for analysis for clinical outcomes. ... Statistical analyses and comparisons were, however, not possible because of the limited number of articles.”
The authors summarized “interesting findings” from the 4 selected articles on clinical outcomes, including a breakout of retention associated with milled CECDs compared with conventional CDs (CCD), phonetics and esthetics comparisons between milled CECDs and other types of CDs, outcomes based on patient selection, number of postplacement adjustment appointments, efficiency of technique, and patient satisfaction.
Although proclaiming the need for long-term clinical studies on CECD before definitive conclusions can be drawn, the authors said that their systematic review “revealed a positive trend in the outcomes for CECDs.” They also offered the caveat that patient selection may have influenced favorable outcomes.
The authors highlighted advantages related to CECDs culled from their literature study, including significantly reduced clinical time. “One of the main advantages cited for CECDs has been the reduced number of appointments (2 visits) compared with the conventional method (5 visits),” they wrote.
The other main advantages they named were improved retention and digital archivability.
They also said, “The introduction of digital technology in CD fabrication streamlines and simplifies the treatment process and offers new and specific applications for patients with complete endentulism.”
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JADA+ Specialty Scans and JADA+ Scans are quarterly newsletters updating dentists on the latest research in selected specialties and disciplines in dentistry. ADA Publishing and the consulting editors from the represented specialties and disciplines aggregate and summarize research from previously published materials, each item attributed to its publication of origin. JADA+ Scan specialties and disciplines include endodontics, oral pathology, orthodontics, pediatric dentistry, periodontics, prosthodontics, radiology, cosmetic/esthetic and osseointegration. The ADA has engaged the specialty organizations in these areas as well as its own Science Institute and Division of Legal Affairs to assist with these newsletters. View past issues here.
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