Anti-resorptive therapy and MRONJ. A survey of the Italian Society of Periodontology and Implantology.

OBJECTIVES: Anti-resorptive agents have been linked to the development of MRONJ in patients undergoing dental surgical procedures. This survey aims to explore the level of knowledge and experience of Italian Society of Periodontology and Implantology members in the management of patients treated with anti-resorptive agents and with the risk of developing MRONJ. MATERIALS AND METHODS: An 18-item questionnaire was submitted by e-mail to the SIdP members. Statistical analyses were carried out. Continuous variables were described as mean ± standard deviation (SD) or median, and first and third quartile according to distribution's normality. Normality of data was checked with Shapiro-Wilk test. RESULTS: Four hundred and fifty-one questionnaires were returned by e-mail (32%). Most of the respondents were private practitioners (81.8%). Only 47.7% declared to be highly confident in managing patients on anti-resorptive therapy while 92.5% reported to have performed tooth extractions and 52.3% implant surgery in patients under anti-resorptive therapy for osteometabolic disorders. One or more MRONJ-affected patients were encountered by 63.2% of the respondents. CONCLUSIONS: This survey highlights the need to develop a "dedicated" program both for dentists and prescribers to improve the level of cooperation and to increase the level of awareness of patients treated with anti-resorptive agents.

Perioperative dental screening and treatment in patients undergoing cardiothoracic surgery and interventional cardiovascular procedures. A consensus report based on RAND/UCLA methodology.

AIM: To reach a consensus on a consistent strategy to adopt when screening patients for dental/periodontal infections and on the feasibility of providing dental treatment before cardiothoracic surgery, cardiovascular surgery or other cardiovascular invasive procedures. METHODOLOGY: A panel of experts from six Italian scientific societies was created. The deliberations of the panel were based on the RAND method. From an initial systematic literature review, it became clear that a consensually validated protocol for the reproducible dental screening of patients awaiting cardiac interventions was considered mandatory by professionals with expertise in the dental, cardiologic and cardiac surgery areas. However, a systematic review also concluded that the treatment options to be provided, their prognosis and timing in relation to the physical condition of patients, had never been defined. Following the systematic review, several fundamental questions were generated. The panel was divided into two working groups each of which produced documents that addressed the topic and which were subsequently used to generate a questionnaire. Each member of the panel completed the questionnaire independently, and then, a panel discussion was held to reach a consensus on how best to manage patients with dental/periodontal infections who were awaiting invasive cardiac procedures. RESULTS: A high level of agreement was reached regarding all the items on the questionnaire, and each of the clinical questions formulated were answered. Three tables were created which can be used to generate a useful tool to provide standardized dental/periodontal screening of patients undergoing elective cardiovascular interventions and to summarize both the possible oral and cardiovascular conditions of the patient and the timing available for the procedures considered. CONCLUSIONS: Upon publication of this consensus document, the dissemination of the information to a wide dental and cardiac audience should commence. The authors hope that this consensus will become a model for the development of a dedicated protocol, ideally usable by heart and dental teams in the pre-interventional preparation phase.

The Effect of Time on Root Coverage Outcomes: A Network Meta-analysis.

The stability of root coverage outcomes has gained a great deal of interest. However, insufficient evidence is available, mainly due to limited direct comparisons among different techniques and the small sample size among clinical trials. Therefore, the aim of this study was to propose a mixed-models network meta-analysis (NMA) that includes the novelty of assessing time on root coverage outcomes while simultaneously comparing different surgical approaches. A literature search was performed by 2 individual reviewers to identify randomized clinical trials (RCTs) reporting the outcomes of root coverage procedures of at least 2 time points to estimate the slopes of different treatment approaches. The primary outcomes were the changes in slopes for recession depth (REC), keratinized tissue width (KTW), and clinical attachment level. Sixty RCTs with a total of 2,554 gingival recessions (1,864 patients) were included in the NMA. Connective tissue graft (CTG) and enamel matrix derivative (EMD) approaches provided superior initial REC reduction compared to flap advancement alone. However, only CTG-based procedures were effective in maintaining the stability of the gingival margin over time, while EMD, acellular dermal matrix, collagen matrix, and flap alone showed a similar tendency for gingival recession recurrence. Baseline REC and KTW at the earliest postoperative recall were predictors for the stability of the gingival margin. In addition, a geographic center effect on the treatment slopes was observed for REC and KTW. While limitations of the present linear mixed-modeling approach should be considered as it refers to estimation and comparison of time slopes based on an examined while linear framework, the designed NMA showed to be an effective tool for the simultaneous comparison of multiple treatment approaches while taking into account the critical element of time.

Perioperative dental screening and treatment in patients undergoing cardio-thoracic surgery and interventional cardiovascular procedures. A consensus report based on RAND/UCLA methodology.

AIM: To reach a consensus on a consistent strategy to adopt when screening patients for dental/periodontal infections, and on the feasibility of providing dental treatment before cardiothoracic surgery, cardiovascular surgery or other cardiovascular invasive procedures. METHODOLOGY: A panel of experts from six Italian scientific societies was created. The deliberations of the panel were based on the RAND method. From an initial systematic literature review, it became clear that a consensually validated protocol for the reproducible dental screening of patients awaiting cardiac interventions was considered mandatory by professionals with expertise in the dental, cardiologic and cardiac surgery areas. However, systematic review also concluded that the treatment options to be provided, their prognosis and timing in relation to the physical condition of patients had never been defined. Following the systematic review several fundamental questions were generated. The panel was divided into two working groups each of which produced documents that addressed the topic and which were subsequently used to generate a questionnaire. Each member of the panel completed the questionnaire independently and then a panel discussion was held to reach a consensus on how best to manage patients with dental/periodontal infections who were awaiting invasive cardiac procedures. RESULTS: A high level of agreement was reached regarding all the items on the questionnaire, and each of the clinical questions formulated were answered. Three tables were created which can be used to generate a useful tool to provide standardized dental/periodontal screening of patients undergoing elective cardiovascular interventions, and to summarize both the possible oral and cardiovascular conditions of the patient and the timing available for the procedures considered. CONCLUSIONS: Upon publication of this consensus document, the dissemination of the information to a wide dental and cardiac audience should commence. The authors hope that this consensus can become a model for the development of a dedicated protocol, ideally usable by heart and dental teams in the pre-interventional preparation phase.

A diagnostic dilemma: endodontic lesion or odontogenic keratocyst? A case presentation.

AIM: To present a clinical case of odontogenic keratocyst (OKC) simulating a lateral periodontal cyst. SUMMARY: A 39-year-old female complaining of swelling and pain in the left mandibular premolar area was found to have a radiolucent lesion between teeth 34 and 35 (FDI). Both teeth had incomplete root fillings, and orthograde re-treatment of both premolars was performed. At 2-year follow-up, radiographic examination showed an increase in the radiolucent defect with respect to the previous examination. A surgical treatment of tooth 34 was then performed, with histological examination of the lesion. Histological features were consistent with an OKC, and the lesion was successfully treated by complete enucleation and application of Carnoy's solution. At 2-year follow-up, no clinical signs or symptoms were found and the radiolucent area had disappeared. KEY LEARNING POINTS: Odontogenic keratocysts may mimic endodontic lesions. Clinicians should carefully review their cases and consider surgical intervention with biopsy in cases that do not heal.

Retrospective evaluation of the influence of the interleukin-1 genotype on radiographic bone levels in treated periodontal patients over 10 years.

BACKGROUND: A difference in genetic susceptibility to plaque accumulation has been advocated to explain different responses to periodontal therapy. The purpose of this study is to assess the role of the interleukin-1 (IL-1) polymorphism on the rate of bone and tooth loss in non-smoking periodontally treated patients during maintenance. METHODS: Sixty consecutive non-smoking patients (mean age 46.8 +/- 5.0) with moderate to severe periodontitis, treated and maintained for over 10 years were selected. At baseline (T0), radiographic evaluation (cemento-enamel junction [CEJ]-root apex, CEJ-bottom of defect mesial and distal, CEJ-bone crest mesial and distal, crown-root ratio) was performed. All patients received scaling and root planing; 36 patients then underwent surgical therapy. Subsequently, all patients were enrolled in a periodontal maintenance program with recall visits every 3.4 +/- 1.0 months for at least 10 years. At the latest recall visit (T2) the same radiographic measurements evaluated at baseline were taken and a DNA sample for IL-1 genetic susceptibility testing was collected and sent for analysis. RESULTS: Twenty-three of the 60 patients (38.3%) were IL-1 genotype positive. A total of 52 teeth (3.3%) out of 1,566 were lost due to periodontitis between T0 and T2; 28 of 957 (2.9%) in the IL-1 genotype negative group and 24 of 609 (3.9%) in IL-1 genotype positive group. The mean variation in bone defect level (DeltaBD) averaged -0.04 mm in IL-1 genotype negative patients and 0.01 mm in IL-1 genotype positive patients. The mean variation in bone crest level (DeltaBC) averaged -0.24 mm in IL-1 genotype negative patients and -0.28 mm in IL-1 genotype positive patients. However, a few patients showed significant differences in response to therapy based on initial bone levels and genotype. IL-1 negative patients who showed minimal initial bone loss responded to the therapy better than the IL-1 positive patients. IL-1 positive patients with severe initial bone loss showed a better response to the therapy than IL-1 negative patients. CONCLUSIONS: On average, there were no significant differences related to IL-1 genotype in tooth loss after 10 years in a non-smoking, well-maintained periodontal population. On an individual patient basis, the IL-1 genotype, in combination with the initial bone level, seems useful at the beginning of therapy for predicting bone level variation.

Coronally advanced flap procedure for root coverage. Flap with tension versus flap without tension: a randomized controlled clinical study.

BACKGROUND: This clinical controlled study was designed to measure the tension of coronally advanced flaps (CAF) performed to treat shallow gingival recessions and to compare the recession reduction (Rec Red) achieved in a test group (flaps with tension) and in a control group (flaps without tension) 3 months after surgery. METHODS: Eleven patients, aged 22 to 41 years, with high levels of oral hygiene (full mouth plaque score <20%) were selected for the study. Each patient showed 2 bilateral Miller Class I maxillary or mandibular gingival recessions located on homologous teeth. A total of 22 recessions were treated. The recession depth at the right site was similar to that at the left site (difference < or =1 mm). For each patient, the 2 recessions underwent CAF procedure in the same surgical session. Before suturing, the residual tension (FTens) of both right and left flaps was measured with a dynamometer. Then, one site was randomly assigned to the test group and the contralateral site to the control group. In the test site the flap was sutured. In the control site the flap was further relaxed, the tension was measured again, and the flap was sutured. RESULTS: In the test group (with tension) the initial mean recession depth was 2.82 +/- 0.64 mm and mean FTens was 6.5 g, while in the control group (without tension) the initial mean recession depth was 2.68 +/- 0.81 mm and mean FTens was 0.4 g. Three months later, the test group showed a mean recession reduction of 2.18 +/- 0.60 mm, a mean percent root coverage of 78 +/- 15%, and complete root coverage was achieved on 2 teeth (18%). In the control group the mean recession reduction was 2.32 +/- 0.81 mm and mean percent root coverage was 87 +/- 13%. Complete root coverage was obtained on 5 teeth (45%). The difference of recession reduction between the test and control group was not statistically significant (P = 0.3911). In the test group, linear regression analysis showed a statistically significant association between recession reduction and both recession depth at baseline (P= 0.0001) and mean of the 3 tensions recorded on the test side (MFTens) (P = 0.0009). CONCLUSIONS: This study shows that minimal flap tension does not influence recession reduction after 3 months when shallow recessions are treated by means of CAF. In the test group (with tension), the statistical analysis suggests that the higher the flap tension, the lower the recession reduction.

[Diabetes mellitus as a risk factor for periodontitis]. / Il diabete mellito come fattore di rischio per la parodontite.

Diabetes mellitus is an important disease of the endocrine system. Many studies have associated this disease to the pathogenesis and the severity of periodontal disease. The aim of this article is to illustrate the relation between diabetes mellitus and periodontal disease. Many studies show an important association between diabetes and the pathogenesis of periodontal disease. Vascular changes caused by hyperglycemia are associated to the development of periodontal pathogens species. Moreover diabetics show an exacerbate host response with hyperproduction of inflammatory mediators and polymorphonuclear dysfunction. Diabetics with good metabolic control and patients with good oral hygiene show a reduced risk of periodontitis. In conclusion, diabetes mellitus (IDDM and NIDDM) is an important risk factor for periodontitis. Odds Ratio is 3. Diabetes mellitus determines changes in bacterial population and production of inflammatory mediators, and reduces the efficacy of the host response. Good controlled diabetes do not cause a major risk of periodontitis and improve the results of the periodontal therapy. Moreover periodontal therapy may reduce the request of insulin in diabetics. It is reasonable a two-ways relation between diabetes and periodontal disease.

[Periodontic-endodontic lesions: diagnostic and therapeutic indications]. / Lesioni endo parodontali. Indicazioni diagnostiche e terapeutiche.

The presence of connections between periodontium and endodontium can lead to the diffusion of an infection from one apparatus to another. The involvement of both periodontium and endodontium is defined as Combined Periodontic-Endodontic lesions. This definition is not based on the initial etiology of the lesion and either the endodontic or periodontal lesion may be the cause or the result of the other or both may develop independently. The lesions must be correctly diagnosed for the best therapeutic approach. The diagnosis is based on clinical symptoms and radiographic analysis; clinical signs must show the presence of periodontal probing and pulpal necrosis. Radiographic examination can confirm the involvement of both periodontium and endodontium only if the lesion is present on the mesial and distal part of the diseased tooth; in the case of a palatal/lingual or vestibular lesion such evidence will not be detectable. The therapeutic approach is always based on an initial endodontic treatment followed, if needed, by the proper periodontal treatment.

Periodontal pathogens in atheromatous plaques. A controlled clinical and laboratory trial.

OBJECTIVE: A possible relationship between periodontitis and cardiovascular disease has been suggested. The aims of this controlled clinical study were: (i) to ascertain the presence of periodontal bacteria DNA [Actinobacillus actinomycetemcomitans, Fusobacterium nucleatum, Porphyromonas gingivalis, Prevotella intermedia, Tannerella forsythensis (formerly Bacteroides forsythus)] in carotid atheromatous plaques and (ii) to assess the concomitant presence of the same periodontal bacteria DNA, if any, in periodontal pockets and in carotid atheroma in the same patient. METHODS: A total of 52 patients scheduled for carotid endarderectomy were enrolled in this study. The test group consisted of 26 dentate patients; the control group included 26 edentulous patients. A complete periodontal examination, including radiographic orthopanoramic and subgingival plaque sample, was performed in the test population. Oral and X-ray examinations were performed in the control group. Atheromatous plaques were harvested during surgical procedure for each dentate and edentulous patient and then sent to the microbiological laboratory. Subgingival plaque samples and carotid specimens were examined using the polymerase chain reaction (PCR) technique by means of specific primers for periodontal bacteria. Amplification of extracted DNA was tested using human beta-globin specific-primers. RESULTS: Out of 52 endarterectomy samples, 12 (seven dentate, five edentulous patients) were excluded as negative to DNA amplification. In subgingival plaque samples of 19 test patients, T. forsythensis (79%), F. nucleatum (63%), P. intermedia (53%), P. gingivalis (37%) and A. actinomycetemcomitans (5%) were found. No periodontal bacteria DNA was detected by PCR in any of the carotid samples in either patient group. CONCLUSION: The presence of periodontal bacteria DNA in atheromatous plaques could not be confirmed by this study and thus no correlation could be established between species associated with periodontal disease and putative bacteria contributing to atheromatous plaques.