Group 3 ITI Consensus Report: Materials and antiresorptive drug-associated outcomes in implant dentistry.

OBJECTIVES: The aim of Working Group 3 was to address the influence of both material- and anti-resorptive drug- related factors on clinical and biological outcomes and complications in implant dentistry. Focused questions were addressed on (a) implant materials other than titanium (alloy)s, (b) transmucosal abutment materials and (c) medications affecting bone metabolism were addressed. MATERIALS AND METHODS: Three systematic reviews formed the basis for discussion in Group 3. Consensus statements and clinical recommendations were formulated by group consensus based on the findings of the systematic reviews. Patient perspectives and recommendations for future research were also conveyed. These were then presented and accepted following further discussion and modifications as required by the plenary. RESULTS: Zirconia is a valid alternative to titanium as material for implant and transmucosal components, allowing soft and hard tissue integration with clinical outcomes-identified by implant survival, marginal bone loss and peri-implant probing depths-up to 5-years comparable to titatnium. However, most of the evidence for zirconia implants is based on 1-piece implants limiting the indication range. Furthermore, based on expert opinion, zirconia transmucosal components might be preferred in the esthetic zone. In patients receiving low-dose bisphosphonate therapy, the rate of early implant failure is not increased, while the long-term effects remain poorly studied. Although it has not been sufficiently addressed, similar outcomes can be expected with low-dose denosumab. A drug holiday is not recommended when considering implant placement in patients treated with low-dose ARD. However, the specific therapeutic window, the cumulative dose and the administration time should be considered. Access to peri-implant supportive care is mandatory to prevent peri-implantitis-related medication-related osteonecrosis of the jaw (MRONJ) or implant-related sequestra (IRS). In patients receiving low-dose anti-resorptive drugs (ARD) therapy, the risk of complications related to implant placement is high, and implant procedures in this specific population should be strictly treated in a comprehensive multidisciplinary center. Finally, healthy dental implants should not be removed before low or high-dose ARD. CONCLUSIONS: Zirconia implants can be an alternative to titanium implants in selected indications. However, the current state of evidence remains limited, especially for 2-piece implant designs. Administration of low-dose ARD did not show any negative impact on early implant outcomes, but careful follow-up and supportive care is recommended in order to prevent peri-implant MRONJ and IRS. Implant placement in high-dose patients must be strictly considered in a comprehensive multidisciplinary center.

Instrumentation during the second stage of periodontal therapy: a European survey.

OBJECTIVES: To gather practice-based information about instrumentation during the second stage of periodontal therapy among the members of the European Federation of Periodontology. METHODS: This survey was conducted to investigate periodontal instrumentation (e.g., frequency, instruments, their maintenance) during the second stage of periodontal therapy. RESULTS: Questionnaires from 2008 responders actively involved in periodontal therapy (general dental practitioners, periodontists, and dental hygienists) were analyzed. The frequency of use of hand and mechanical instruments was similar during the second stage of periodontal therapy and 94.4% of the participants combined both. The most popular hand instruments were Gracey curettes, and the preferred mechanical devices were ultrasonic scalers. For the latter, mostly the combination of standard and micro/slim inserts was preferred (42.4%) over solely standard inserts (32.1%) or micro/slim inserts (25.5%). The wear of hand instruments was sytematically checked by 46.1% of the respondents and the wear of the inserts by 41.3%. The more experienced the dental professional, the more frequent the wear of the instruments and inserts was checked. CONCLUSION: The most popular periodontal instrumentation technique in clinical practice during the second stage of periodontal therapy is a combination of hand and mechanical instruments. CLINICAL RELEVANCE: Clinicians should check the wear of their instruments systematically to have the most performant instruments possible for periodontal instrumentation. Scientists should see the results of this questionnaire as an incentive to set up studies investigating whether the combination of hand and mechanical instruments, the preferred treatment method of clinicians, is better than either of these instruments alone.

Novel natural product-based oral topical rinses and toothpastes to prevent periodontal diseases.

There is increasing public interest in natural or herbal-based healthcare products. This trend is not only visible in supermarkets and dental practices, but also in the scientific world. An improving number of clinical trials are being conducted to validate the claims made about these products in regards to periodontal health. Among single component preparations, Aloe vera and green tea are the most studied natural ingredients. Concerning polyherbal mixtures, triphala has garnered great interest. The effects of these natural products on periodontal health is encouraging, with almost all studies showing an inhibitory effect on plaque accumulation and an improvement in gingival health. However, more studies are needed to be able to design clinical guidelines to guide the use of these natural products in periodontal practice. For most of these products, few studies are available and, moreover, the available studies are limited in duration, the number of participants, and the specific composition of the natural product is often not described in detail.

Alveolar bone level at deciduous molars in Flemish children: A retrospective, radiographic study.

AIM: The aim of this retrospective radiographic study in Flemish children was to examine the bone level and bone loss around deciduous molars and factors influencing this. MATERIALS AND METHODS: Two thousand eight hundred ninety six digital intra-oral radiographs of children younger than 18 years old were screened for eligibility. The distance from the cementoenamel junction to the alveolar bone crest was measured, and tooth surfaces were screened for local risk factors that are presumably related to changes in the bone level. A distance >2 mm was defined as bone loss based on previous literature. All measurements were performed by two examiners. RESULTS: One thousand four hundred ninety one radiographs of 796 patients (mean age 6.46 ± 2.38 years) were included. The distance between the cementoenamel junction and the alveolar bone crest ranged from 0.07 to 2.88 mm, and the mean distance was 0.93 ± 0.37 mm. This distance was positively correlated with age (p < .001). In 3.5% of patients, bone loss was diagnosed. Caries, fillings and pulp pathology were associated with bone loss and higher cementoenamel junction-alveolar bone crest distances (p < .05). CONCLUSION: This study found a low prevalence of alveolar bone loss in the primary dentition. Both the bone level and bone loss were strongly correlated with local factors.

A dual-strain Lactobacilli reuteri probiotic improves the treatment of residual pockets: A randomized controlled clinical trial.

AIM: To examine the adjunctive effect of a Lactobacillus reuteri probiotic (ATCC PTA 5289 & DSM 17938) on the re-instrumentation of residual pockets. MATERIALS AND METHODS: This randomized, double-blind, placebo-controlled study included 39 previously non-surgically treated periodontitis patients. A re-instrumentation was carried out, and probiotic and/or placebo drops were applied according to the study protocoll. Patients afterwards received lozenges to use 2×/day for 12 weeks. Probing pocket depth (PPD), recession, bleeding on probing and plaque levels were analysed, next to the microbiological impact. RESULTS: No effects of the probiotic drops could be found. However, after 24 weeks, the overall PPD in the probiotic lozenges group (2.64 ± 0.33 mm) was significantly lower compared to the control lozenges (2.92 ± 0.42 mm). This difference was even more pronounced in moderate (4-6 mm) and deep (≥7 mm) pockets. In the probiotic lozenges group, there were also significantly more pockets converting from ≥4 mm at baseline to ≤3 mm at 24 weeks (67 ± 18% versus 54 ± 17%) and less sites in need for surgery (4 ± 4% versus 8 ± 6%). However, the probiotic products did not influence the microbiological counts of the periodontopathogens. CONCLUSION: The adjunctive consumption of L. reuteri lozenges after re-instrumentation improved the PPD reduction, without an impact on pocket colonization with periodontopathogens.

The usage of a lactobacilli probiotic in the non-surgical therapy of peri-implantitis: A randomized pilot study.

OBJECTIVES: Examine the clinical and microbiological benefits of a dual-strain Lactobacillus reuteri probiotic on the non-surgical therapy of initial peri-implantitis. MATERIALS AND METHODS: This randomized, double-blind study targeted patients with initial peri-implantitis, that is peri-implantitis with a maximum mean probing pocket depth of 6 mm and maximum 3 mm bone loss compared with loading. A full-mouth prophylaxis was performed and the peri-implantitis sites were debrided. Subsequently, local application of the study drops was carried out at the peri-implantitis sites and the study lozenges were handed out. The patients in the probiotic group received drops and lozenges containing L. reuteri (ATCC PTA 5289 & DSM 17938), those in the control group received placebo products. At the implant level the measurements of interest were bleeding, probing pocket depth and plaque. Full-mouth bleeding and plaque scores were also recorded. Microbiological samples were taken from the tongue, saliva and subgingivally around the implants. RESULTS: All clinical parameters were significantly decreased after 12 and 24 weeks. At the implant level the only statistically significant difference was a greater decrease in plaque levels in the probiotic versus the control group (p = .002 at 24 weeks). At the full-mouth level, the only intergroup difference was the greater decrease in full-mouth bleeding on probing sites in the probiotic group compared with the control group (p < .001 at 24 weeks). Concerning the microbiological outcomes, no significant differences could be found at any time point, neither intra- nor intergroup. CONCLUSIONS: No adjunctive effects of the use of L. reuteri probiotics in the treatment of peri-implantitis were found.

Periodontal screening and referral behaviour of general dental practitioners in Flanders.

OBJECTIVES: The objective of this study was to investigate the screening and referral behaviour of Flemish dentists concerning periodontitis and more specific, the use of the Dutch Periodontal Screening Index (DPSI). MATERIALS AND METHODS: An online questionnaire was electronically distributed through the different professional dental societies. It consisted of two parts: the first aimed at describing the profile of the dentist. The second part inquired the screening method, when this was applied, periodontal risk factors and referral behaviour. RESULTS: One thousand fifty dentists attended to the questionnaire. One hundred fifty-nine questionnaires were excluded since they did not match the target audience. Sixty-four percent of Flemish dentists used DPSI as a periodontal screening method, 28% screened based on probing pocket depth, 4% used solely radiographs and 4% had no screening method at all. The usage of DPSI is influenced by the year of graduation: the longer the dentists were graduated, the less they used DPSI. No influence of sex, education centre and location was found. Referral behaviour is influenced by different patient- and dentist-related factors. CONCLUSIONS: Regarding the screening behaviour, there seems a consensus among Flemish dentists that a periodontal probe should be used. For referral, there is no consensus about if and when to refer to a specialist. CLINICAL RELEVANCE: It is encouraging that 92% of the Flemish general dental practitioners use a probe when screening for periodontitis. However, DPSI is mainly used by younger dentists. An effort should be made to encourage all dentists to use this, so that in every patient, periodontitis can be detected timely, securing the best treatment outcome.

Subgingival debridement: end point, methods and how often?

Subgingival debridement is the part of nonsurgical therapy which aims to remove the biofilm without intentionally removing the cementum or subgingival calculus. The objective of this review was to describe the end point of this therapy, the different methods used and how often it should be carried out. The literature shows that several methods are currently available for subgingival debridement, namely hand instrumentation, (ultra)sonic instrumentation, laser, photodynamic therapy and air-polishing. None of these methods seems superior to any other regarding clinical benefits or microbiological differences. However, less treatment discomfort is reported using laser, photodynamic therapy or air-polishing compared with hand- and/or (ultra)sonic instrumentation. Subgingival debridement can be carried out when, during supportive periodontal therapy, pockets of 5 mm or deeper are detected.

Periodontal diseases as a source of halitosis: a review of the evidence and treatment approaches for dentists and dental hygienists.

Bad breath (halitosis) is an important social complaint. In most cases (≥90%), the cause of halitosis can be found within the oral cavity. Under this circumstance, the term oral malodor applies. It affects both healthy and periodontally diseased individuals. Oral malodor is mainly caused by a microbial degradation of both sulfur-containing and nonsulfur-containing amino acids into volatile, bad-smelling gases. Anaerobic gram-negative bacteria, the same species that have been linked to periodontal diseases, are especially involved in this process, explaining why clinicians often associate oral malodor with periodontitis. Some volatile organic compounds render patients more susceptible to periodontitis and this supports the malodor-periodontitis link. This review investigates the interaction between oral malodor and periodontal diseases. Pro and con arguments regarding the mechanisms of halitosis and clinical implications will be presented. In general, however, the impact of tongue coatings has been found to be the dominant factor, besides gingivitis and periodontitis. The last part of this review discusses the treatment of bad breath, with different options.

The effect of a streptococci containing probiotic in periodontal therapy: a randomized controlled trial.

AIM: To evaluate the adjunctive effects of a Streptococcus oralis KJ3, Streptococcus uberis KJ2 and Streptococcus rattus JH145 containing probiotic tablet after scaling and root planing (SRP). MATERIALS AND METHODS: Forty-eight periodontitis patients were included in this double-blind, placebo-controlled clinical trial. After root planing, patients used either a placebo or a probiotic tablet twice a day for 12 weeks. The pocket probing depth (primary outcome measure), bleeding on probing and relative attachment levels were measured at baseline, 12 and 24 weeks. At baseline, 4, 8, 12 and 24 weeks, microbiological sampling was performed and plaque and gingival indices were recorded. RESULTS: The primary and secondary outcome measures were significantly (p < 0.05) improved at the 12- and the 24-week evaluation in both groups. However, no significant inter-group differences could be detected at any time point, except from the % of sites with plaque that were significantly lower in the probiotic group than in the control group at the 24-week evaluation. In addition, at the 12-week time point, the salivary Prevotella intermedia counts were significantly lower in the probiotic group. CONCLUSIONS: No differences were detected when comparing the adjunctive use of a placebo or the investigated streptococci containing probiotic tablet after SRP. ClinicalTrials.gov Identifier: NCT02403960.

Computer-supported implant planning and guided surgery: a narrative review.

AIM: To give an overview of the workflow from examination to planning and execution, including possible errors and pitfalls, in order to justify the indications for guided surgery. MATERIAL AND METHODS: An electronic literature search of the PubMed database was performed with the intention of collecting relevant information on computer-supported implant planning and guided surgery. RESULTS: Currently, different computer-supported systems are available to optimize and facilitate implant surgery. The transfer of the implant planning (in a software program) to the operative field remains however the most difficult part. Guided implant surgery clearly reduces the inaccuracy, defined as the deviation between the planned and the final position of the implant in the mouth. It might be recommended for the following clinical indications: need for minimal invasive surgery, optimization of implant planning and positioning (i.e. aesthetic cases), and immediate restoration. CONCLUSIONS: The digital technology rapidly evolves and new developments have resulted in further improvement of the accuracy. Future developments include the reduction of the number of steps needed from the preoperative examination of the patient to the actual execution of the guided surgery. The latter will become easier with the implementation of optical scans and 3D-printing.

Implant connection and abutment selection as a predisposing and/or precipitating factor for peri-implant diseases: A review.

Peri-implant mucosal integration is becoming a critical aspect for long term implant health and can be triggered the selection of implant components. The aim of this review is therefore to investigate the evidence concerning implant connection and abutment characteristics (abutment materials, design, handling) as predisposing or precipitating factor for peri-implant mucositis and peri-implantitis. Although the evidence that these features can directly predispose/precipitate peri-implant diseases is limited, there are -few- studies showing a potential role of the implant connection, trans-mucosal configuration, and handling in the development of early bone loss and/or peri-implantitis. With bone level implants, conical internal connections (with inherent platform switching) might be preferred over internal flat-flat and external connections to decrease the risk of early bone loss and potentially the risk of peri-implant disease. Moreover, there is a trend suggesting moving the prosthetic interface coronally (to the juxta-mucosal level) as soon as possible to reduce the number of disconnections and to limit the risk of cements remnants. This can be achieved by choosing a tissue-level implant or to place a trans-mucosal abutment (one abutment-one time approach) to optimize the peri-implant soft tissue seal. In absence of evidence for the biocompatibility regarding several restorative materials, biocompatible materials such as titanium or zirconia should be preferred in the trans-mucosal portion. Finally, higher implants (≥2mm) with an emergence angle below 30° seem more favourable. It should however be noted that some of this information is solely based on indirect information (such as early bone loss) and more research is needed before making firm recommendations about abutment choice. [Correction added on 13 March 2023, after first online publication: 'longer implants (≥2mm)' was changed to 'higher implants (≥2mm)' in this version.].

Association of nine pathobionts with periodontitis in four South American and European countries.

Aim: Our aim was to compare the prevalence and load of nine pathobionts in subgingival samples of healthy individuals and periodontitis patients from four different countries. Methods: Five hundred and seven subgingival biofilm samples were collected from healthy subjects and periodontitis patients in Belgium, Chile, Peru and Spain. The prevalence and load of Eubacterium brachy, Filifactor alocis, Fretibacterium fastidiosum, Porphyromonas endodontalis, Porphyromonas gingivalis, Selenomonas sputigena, Treponema denticola, Tannerella forsythia and Treponema socranskii were measured by quantitative PCR. Results: The association with periodontitis of all species, except for T. socranskii, was confirmed in all countries but Peru, where only P. endodontalis, P. gingivalis and T. denticola were found to be significantly associated. Moreover, most species showed higher loads at greater CAL and PPD, but not where there was BOP. Through Principal Component Analysis, samples showed clearly different distributions by diagnosis, despite observing a smaller separation in Peruvian samples. Conclusions: Unlike prevalence, relative load was found to be a reliable variable to discriminate the association of the species with periodontitis. Based on this, F. alocis, P. endodontalis, P. gingivalis, T. denticola and T. forsythia may be biomarkers of disease in Belgium, Chile and Spain, due to their significantly higher abundance in periodontitis patients.

Can Periodontitis Influence the Progression of Abdominal Aortic Aneurysm? A Systematic Review.

There is some evidence that periodontitis increases the risk of atherothrombosis. Abdominal aortic aneurysm (AAA) is a cardiovascular disease with specific risk factors and physiopathological mechanisms that can lead to rupture in the absence of treatment. The aim of the present systematic review was to explore the influence of periodontitis on the progression of AAAs as a specific disease. A systematic search in PubMed/MEDLINE and Embase databases was performed. Human and animal studies exploring the influence of periodontal pathogens on the progression of AAA were considered for inclusion. After systematic screening, 5 articles were included in the review. Due to the heterogeneity of the selected studies, a meta-analysis could not be performed. The descriptive analyses of the studies emphasized that periodontal pathogens or their by-products contribute to systemic and local innate immunity likely to be associated with AAA physiopathology. Periodontitis seems to play a role in the development and progression of AAA. The present systematic review suggests that the presence of periodontal bacteria in the bloodstream or in situ in the vascular lesion is a risk associated with aneurysmal disease progression.

The Influence of a Bifidobacterium animalis Probiotic on Gingival Health: A Randomized Controlled Clinical Trial.

BACKGROUND: There is growing interest in the use of probiotics in periodontal therapy; however, until now, most research has focused on lactobacilli probiotics. The aim of this study is to evaluate the effect of 4-week use of yogurt supplemented with Bifidobacterium animalis subsp. lactis DN-173010 versus a placebo yogurt, followed by a 5-day non-brushing period. METHODS: Individuals were included in this single-mask, randomized, controlled study if probing depth (PD) was ≤3 mm and attachment loss was ≤2 mm. After professional prophylaxis, they were randomized into two groups receiving yogurt containing either placebo or B. animalis for 28 days, followed by a 5-day non-brushing period. Outcome measures were plaque index (PI), gingival index (GI), bleeding on probing (BOP), PD, gingival crevicular fluid (GCF) volume, and total amount and concentration of interleukin (IL)-1ß in GCF. These were measured at baseline, after 28 days of study product use, and subsequently after 5 days of plaque accumulation. RESULTS: Fifty-one patients were analyzed. No intergroup differences could be detected before and after intake of study products. However, after plaque accumulation, significantly better results for all parameters were seen in the probiotic group compared with the control group (P <0.001): lower PI and GI, less BOP, less increase in GCF volume, and lower IL-1ß total amount/concentration. CONCLUSION: The use of a probiotic yogurt supplemented with B. animalis can have a positive effect on plaque accumulation and gingival inflammatory parameters after refraining from oral hygiene practices.

Guided Implant Surgery in the Edentulous Maxilla: A Systematic Review.

PURPOSE: This systematic review verified the usefulness/limitations of static surgical guides during implant surgery in the edentulous maxilla. The PICO question was: "Does the use of digitally generated surgical guides vs conventional techniques affect the following outcomes: surgical complications, implant complications, prosthesis complications, implant survival, prosthesis survival, economics, patient satisfaction, and maintenance intervention?" MATERIALS AND METHODS: The electronic searches retrieved 2,588 unique articles from which eventually 36 full-text articles were read for eligibility. Because no randomized controlled clinical trials could be found, the PICO question had to be reformulated, now only looking to the outcome of digitally generated surgical guides without comparison with conventional techniques. RESULTS: Although long-term data are lacking, the outcome of implants placed with a static guide and of the prosthetic reconstruction seems similar to that expected from conventional techniques. The number of surgical complications with guided surgery is negligible. Guided flapless implant surgery offers slightly more comfort for the patient; however, the economic benefits are unclear. CONCLUSION: Implant therapy via static surgical guides in the maxilla is predictable, with slightly more comfort for the patient but with only minor economic advantages.

Probiotics in the dental practice: a review.

During the last decade an increased interest in alternative, preventive, and therapeutic strategies in dentistry has arisen. Probiotics are living microorganisms which, if administered in sufficient amounts, provide a health benefit to the host. Their precise mechanisms of action have not been identified, but they are able to interfere with the imbalance occurring in biofilm-associated infections. In other fields of medicine, mainly in gastroenterology, their usefulness is already proven. Concerning oral threats, probiotic bacteria may reduce the numbers of pathogens associated with dental caries (mutans streptococci). Clinically, results are encouraging, but further research is needed to demonstrate apparent effects of certain probiotic strains on oral health as well as their desired concentration and vehicle. The use of probiotics in prevention and treatment of caries, periodontal diseases, halitosis, and other oral diseases needs to be further investigated.

The role of toothpastes in oral malodor management.

One out of four people suffers from persistent bad breath. In most of the cases, the cause can be found in the mouth, with the presence of tongue coating as the leading factor, followed by gingivitis and periodontitis, and it is referred to as oral malodor. Because oral malodor is the result of the degradation of organic substrates by anaerobic bacteria of the oral cavity, the management is mostly done by masking the odorous compounds or eliminating the cause (bacteria and their substrates) either mechanically or chemically. Toothpaste formulations have been modified to carry antimicrobial and oxidizing agents with an impact on the process of oral malodor formation. We performed extensive literature search regarding the effect of dedicated toothpastes in the management of oral malodor. The main characteristics of the in vitro and in vivo investigations and their most relevant findings are presented for discussion. Even though the amount of publications regarding this topic is far smaller than for others such as caries, plaque control and whitening, antibacterial ingredients such as triclosan and metal ions like stannous and zinc appear to be effective in the control of oral malodor. On the other hand, data supporting the use of hydrogen peroxide, baking soda, essential oils and flavors in the management of oral malodor are rather few and inconclusive.

Usefulness of a new malodour-compound detection portable device in oral malodour diagnosis.

A new device (BB Checker) able to detect malodour compounds has recently been made available. This retrospective analysis aimed at evaluating the usefulness of this device as adjunct tool for the diagnosis of oral malodour. Data from 100 consecutive volunteers with bad breath complaints attending their first consultation at a halitosis clinic were analysed. In addition to the standard protocol (organoleptic ratings from mouth and nose air, and from tongue coating when present; OralChroma and Halimeter measurements from mouth air; and intra-oral examinations), oral, exhaled and nasal air samples were examined with the BB Checker. We could not establish a correlation between the BB Checker values and the organoleptic scores, or the sulfur-compound levels determined by the OralChroma or the Halimeter (R < 0.3, p > 0.05). The overall sensitivity and specificity of the new device did not exceed the 50%. The correlations between the organoleptic scores and the OralChroma and the Halimeter measurements were good and in line with previous reports (R between 0.56 and 0.73). Our results do not favour the use of the BB Checker as adjunct tool in the diagnosis of oral malodour.

The role of Solobacterium moorei in oral malodour.

This study aims to analyze the correlation between Solobacterium moorei (S. moorei), both on the tongue and in saliva, and several oral malodour- and clinical parameters. Data from 193 patients visiting a halitosis clinic were used for analysis. A questionnaire assessed their general health, allergies, medication, smoking habits and oral hygiene. Following halitosis parameters were recorded: organoleptic score (OLS) (0-5), total concentration of volatile sulfur compounds (VSC) (Halimeter), individual concentrations of VSC (Oral Chroma), tongue coating (MTCI, WTCI and mWTCI), salivary parameters (flow rate and pH), oral hygiene, tonsil health and periodontal health. In all subjects, microbiological samples were collected from the tongue coating and from the saliva, and a quantitative polymerase chain reaction was performed to detect S. moorei. A significant correlation could be established between S. moorei, from both tongue and saliva, and several breath parameters (OLS, H2S, CH3SH, (CH3)2S and total VSCs), tongue coating indices and periodontal indices (gingivitis, periodontitis and oral hygiene). This study suggests a strong association between the presence of S. moorei and oral malodour (s54747).