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JADA Specialty Scan - Radiology
Periodontics - A Quarterly Newsletter on Dental SpecialtiesJADA Specialty Scan

Interdental brushes, water jets, top IOH habits to fight gingival bleeding

Interdental brushes and water jets top the list of interproximal oral hygiene (IOH) habits to reduce gingival bleeding, while toothpicks and floss rank last. The findings come from a study conducted at the University of Washington. The article was published in the May issue of Journal of Periodontology.

The authors conducted a meta-analysis of 22 studies to compare the efficacy of IOH aids in reducing gingival inflammation using Bayesian Network Meta-Analysis (BNMA). A random-effects arm-based BNMA model was run for each outcome; posterior medians and 95% confidence intervals (CIs) summarized marginal distributions of parameters. Reduction in gingival inflammation, measured by means of the gingival index (GI) and bleeding on probing (BoP), was the primary outcome. Reduction in plaque and probing depth was the secondary outcome.

From the 22 studies the authors identified 10 major IOH categories of oral hygiene habits: flossing, powered flossing, toothpicks, toothpicks and intensive oral hygiene instructions, water jet irrigation devices, interdental brushes, gum massaging devices, toothbrush only, powered, electric, sonic toothbrush, powered control and water jet. The number of participants in each study ranged from 10 through 110.

Authors used the BNMA to assess the probability of each treatment being the best intervention. They identified “best” as the one with the highest estimated posterior probability of ranking first among all the tested interventions.

Overall, authors found that interdental brushing reduced the most GI with a mean of 0.23 (95% CI, 0.09 to 0.37). Water jets ranked second with a mean reduction of 0.19 (95% CI, 0.14 to 0.24). Toothpicks and intensive oral hygiene instructions had the most probability of reducing BoP compared with control (26.4% [95% CI, 7.50 to 45.4]). The second greatest reduction in BoP against control was noted for water jet with an average of 19.3% (95% CI, 16.2% to 22.4%).

Raking based on posterior probability showed that toothpick with intensive oral hygiene instruction and water jet irrigation devices ranked “best” to reduce BoP (70.4% and 12.6%, respectively). Interdental brushing and water irrigation devices ranked “best” to reduce GI (64.7% and 27.4%, respectively). The probability of toothpick and floss being the “best” IOH aids was near zero.

Still, the authors suggested that flossing’s low ranking stemmed more from lack of consistent use than from lack of efficacy. “Our findings support the hypothesis that flossing is indeed efficacious, but its effective application is elusive,” they noted. “Given the prevalence of gingivitis, providing the general public with efficacious alternatives to flossing would likely have significant public health impact.”

Read the original article here.


Consulting Editor: Tapan Koticha, BDS
Diplomate, American Board of Periodontology
Director, Graduate Periodontics
University of Oklahoma Health Sciences Center, College of Dentistry

Scaling and root planing and diabetes: an update

Scaling and root planing (SRP) produces a statistically significant reduction in glycated hemoglobin (HbA1C) levels at 3 months of about 0.40% (range, 0.27%-0.65%), while at 6 months, the estimated reduction is lower. Antibiotics do not add significantly to the effect of SRP alone on HbA1c levels of patients with type 2 diabetes mellitus. These findings are from a review and meta-analysis published in the February issue of Journal of Clinical Periodontology.

Authors conducted the review to update the 2013 article by Engebretson and Kocher* on effect of periodontal therapy on glycemic control of people with diabetes. The current systematic review includes 7 meta-analyses published from January 2013 through February 2017.

Authors found that a reduction in HbA1c levels at 3 through 4 months was reported in all reviews for the treatment group ranging from −0.27% (95% confidence interval [CI], −0.46 to −0.07, P = .007) through −1.03% (95% CI, 0.36 to −1.70, P = .003). The 5 most recent meta-analyses (2014-2016) showed a reduction ranging from −0.27% (95% CI, −0.46 to −0.07, P = .007) through −1.03% (95% CI, 0.36 to −1.70, P = .003). The 4 reviews that reported data at 6 months showed an HbA1c reduction ranging from −0.02 (95% CI, −0.20 to −0.16, P = 0.84) through −1.18% (95% CI, 0.72% to 1.64%, P < .001).

Authors measured the reduction in fasting plasma glucose at 3 through 4 months in 4 studies and found that it ranged from –8.95 milligrams per deciliter (95% CI, −4.30 to –13.61, P = .0002) through −9.04 mg/dL (95% CI, −2.17 to −15.9, P < .05). Fasting plasma glucose at 6 months, reported only in 1 study, was −13.62 mg/dL (95% CI, 0.45 to −27.69, P = .06).

Authors compiled data from 2 reviews on the effect of periodontal treatment with the adjunctive use of antibiotics compared with no or delayed treatment on HbA1c levels. Authors of the first review found that the result was nonsignificant (P = .734), while authors of the other review found that it had a positive effect on HbA1c reduction of −0.89% (95% CI, −0.84 to −0.94, P = .04).

Authors compiled data from 3 meta-analyses that compared the effect of SRP plus antibiotics with SRP alone in reducing HbA1c after a 3- through 4-month period. Among them, authors noted a diversity of antibiotics used, along with the way they were administered (systemic or topical). The result in all 3 reviews was nonsignificant 0.00% (95% CI, −0.22% through 0.22%, P = .16).

“Successful periodontal treatment which results in the reduction in inflammation from the periodontal tissues improves the metabolic control of people with diabetes mellitus,” the authors noted. “Data derived from this update, which is a review of the meta-analyses and systematic reviews that evaluate the effect of periodontal therapy (with or without the adjunct use of antibiotics) on the glycemic control of people with types 1 or 2 diabetes mellitus (DM) published between 2013 and 2017, are in accordance with earlier data.”

Read the original article.

*Engebretson S, Kocher T. Evidence that periodontal treatment improves diabetes outcomes: a systematic review and meta‐analysis. J Clin Periodontol 2013; 40 (suppl. 14): S153–S163. doi: 10.1111/jcpe.12084.


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Efficacy of tunnel technique in the treatment of localized and multiple gingival recessions


Tunnel technique (TUN) remains an effective way to treat local and multiple gingival recession (GR) defects, according to an article published online May 14 in Journal of Periodontology.

Authors conducted a systemic review and meta-analysis with 4 goals: to measure the predictability of TUN in localized and multiple GR defects, to study the impact of each procedure on different Miller GR classifications (class I, II, and III), to name factors that influence the final mean root coverage (mRC) and complete root coverage (CRC), and to compare the outcomes of TUN and the coronally advanced flap (CAF) technique when treating localized and multiple GR defects.

Authors used the Preferred Reporting Items Systematic review and Meta-analyses statement and checklist and the Patient, Intervention, Comparison, Outcomes method as part of their review. Electronic and manual literature searches covered studies published until November 2017 across the National Library of Medicine, EmbaseE, and the Cochrane Oral Health Group Trials Register. Primary outcomes were the mRC and CRC, and the secondary outcomes were keratinized tissue (KT) gain and root coverage esthetic scores.

The systemic review consisted of 20 studies reporting on 1,181 GRs in 439 patients treated using the TUN. Authors used 6 randomly controlled trials for the meta-analysis. The Cochrane Risk of Bias Tool for Randomized Controlled Trials was used to evaluate randomized controlled trials. The Joanna Briggs Institute Scale for Case Series provided guidelines for assessing the risk of bias. Authors used fixed-effects models for their regression analyses.

None of the studies included patients who smoked. A total of 5 articles focused only on localized GRs, and 3 treated single and multiple GRs. The remaining studies included only multiple GRs. One article treated only Miller class III GRs, 3 studies included Miller class I, II, and III GRs, and the remaining articles focused only on Miller class I and II GRs.

The overall mRC (standard deviation) of the TUN for localized GRs was 82.75% (19.7%), while the mRC of the TUN for multiple GRs was 87.87% (16.45 %). The CRC of the TUN was lower in localized than multiple GRs (47.15% and 57.46%, respectively).

Linear regression analysis showed that maxillary GRs, split-thickness flaps, and a suture diameter 6-0 or greater were significantly associated with a greater mRC (P < .001). Meta-regression analyses found that single versus multiple recession treatment, the location of the treated GR (maxilla or mandible), the study setting (private practice or university setting), and the follow-up period (4, 6, or 12 months) had no significant effect (P > .05) on the results of the performed meta-analysis.

CRC was significantly influenced by RecDepth0 2.5 millimeters or less (P < .05), a split-thickness flap (P < .001), and a suture diameter narrower than 6-0 or greater (P < .05). KT gain was not affected by connective tissue graft (CTG) or substitutes, RecDepth0, flap thickness, papillae elevation, suture diameter, suture technique, or recession area (P > .05).

The analysis of CRC for all studies did not statistically favor either group (P  = .3), but a subgroup analysis of trials using only CTG or acellular dermal matrix (ADM) found a significant P value of .003 and.0007, respectively, both in favor of the CAF technique. A much higher number of GRs achieved a CRC when treated with CAF technique plus CTG or CAF technique plus ADM compared with TUN plus CTG and TUN plus ADM.

Authors noted no significant difference in changes of KT when comparing the TUN and the CAF technique. The weighted mean difference between the 2 groups was –0.09 (95% confidence interval [CI], –0.50 to 0.32; P = .6) when all articles were analyzed and –0.16 (95% CI, –0.42 to 0.10], P = .2) when only the 2 trials using a CTG were assessed.

Read the original article here.


Accuracy of implant placement with computer-guided surgery

In vitro studies rank higher than clinical and cadaver studies for implant placement accuracy, especially with regard to horizontal apical deviation and angular deviation. Full-guided implant surgery is more accurate than half-guided surgery. These findings are from a study conducted at the University of Valencia in Spain. These results, published in the January/February issue of International Journal of Oral and Maxillofacial Implants, could help put accuracy studies of guided surgery in perspective.

Authors conducted the systematic review and meta-analysis with a 2-fold purpose: to compare implant accuracy in implant patients, cadavers and in vitro models and to compare the accuracy of half-guided implant surgery with full-guided implant surgery.

Authors conducted a MEDLINE database search for articles published from 2005 through 2015. Search terms included “reliability AND dental implant planning” and “accuracy dental implant planning.” Inclusion criteria included in vitro, clinical, and cadaver studies that specified the deviation (horizontal coronal, horizontal apical, and angular) in implant position from prior virtual planning; prospective and retrospective studies with or without a control group; and at least 10 implants placed with guided surgery.

After an initial search yielded 186 articles, the authors chose 34 that met inclusion criteria. They compiled data on 3,033 implants in 8 in vitro studies (543 implants), 4 cadaver studies (246 implants), and 22 clinical studies (2,244 implants). Data also were provided for vertical deviation in 14 studies.

Mean horizontal coronal deviation for cadaver studies was least for in vitro models. Differences were not statistically significant between cadaver and in vitro studies, or cadaver and clinical studies, but the in vitro group showed less deviation than the clinical group. In the full-guided group, the authors noted significantly more horizontal coronal deviation when implants were not placed full-guided. Only cadaver studies showed statistically significant differences.

Mean horizontal apical deviation was highest in cadaver studies and least in in vitro studies. Authors noted deviation in in vitro studies was significantly smaller in cadaver and clinical studies. Implants placed with full-guided surgery yielded lower deviation values than those placed with half-guided surgery.

Mean angular deviation in cadaver studies was most for clinical studies, and least for in vitro studies. Authors found statistically significant differences between in vitro and clinical studies. Implants placed with full-guided surgery reached lower deviation values than implants placed with half-guided surgery.

Of the 14 studies that measured vertical deviation, cadaver studies had the lowest values and clinical studies had the highest.

“The average deviation values must be considered when evaluating safety distances, especially with templates for flapless surgery,” the authors noted, “but it is also important to take into account the maximum deviation, which is crucial for preventing damage to anatomical structures.”

Read the original article.

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AAP publishes updated periodontal, peri-implant disease classification

The American Academy of Periodontology (AAP) has published the official proceedings from the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions. These proceedings provide a comprehensive update to the previous disease classification established at the 1999 International Workshop for a Classification of Periodontal Diseases and Conditions.

Highlights from the 2017 proceedings include:

  • Multi-dimensional staging and grading system for periodontitis classification (similar to an oncology model).
  • Recategorization of various forms of periodontitis.
  • Inaugural classification for peri-implant diseases and conditions.

The complete suite of review papers and consensus reports from the workshop, which was co-presented by the European Federation of Periodontology (EFP), is available in the June 2018 print and online issues of the Journal of Periodontology. Click here to read the proceedings, download practice resources, and check out the special behind-the-scenes “Making of the Workshop” documentary.


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JADA+ Specialty Scans and JADA+ Scans

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. View past issues here.

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