Impact of introducing procalcitonin testing on antibiotic usage in acute NHS hospitals during the first wave of COVID-19 in the UK: a controlled interrupted time series analysis of organization-level data.

BACKGROUND: Blood biomarkers have the potential to help identify COVID-19 patients with bacterial coinfection in whom antibiotics are indicated. During the COVID-19 pandemic, procalcitonin testing was widely introduced at hospitals in the UK to guide antibiotic prescribing. We have determined the impact of this on hospital-level antibiotic consumption. METHODS: We conducted a retrospective, controlled interrupted time series analysis of organization-level data describing antibiotic dispensing, hospital activity and procalcitonin testing for acute hospitals/hospital trusts in England and Wales during the first wave of COVID-19 (24 February to 5 July 2020). RESULTS: In the main analysis of 105 hospitals in England, introduction of procalcitonin testing in emergency departments/acute medical admission units was associated with a statistically significant decrease in total antibiotic use of -1.08 (95% CI: -1.81 to -0.36) DDDs of antibiotic per admission per week per trust. This effect was then lost at a rate of 0.05 (95% CI: 0.02-0.08) DDDs per admission per week. Similar results were found specifically for first-line antibiotics for community-acquired pneumonia and for COVID-19 admissions rather than all admissions. Introduction of procalcitonin in the ICU setting was not associated with any significant change in antibiotic use. CONCLUSIONS: At hospitals where procalcitonin testing was introduced in emergency departments/acute medical units this was associated with an initial, but unsustained, reduction in antibiotic use. Further research should establish the patient-level impact of procalcitonin testing in this population and understand its potential for clinical effectiveness.

Factors Affecting Predictability of Buccal Bone Augmentation in Surgically Facilitated Orthodontic Treatment: Surgical Considerations.

The purpose of surgically facilitated orthodontic treatment (SFOT) is to increase and thicken the periodontal biotype, including both hard and soft tissue, and facilitate accelerated tooth movement through the induction of the regional acceleratory phenomenon. This article discusses the surgical and biomaterial factors related to increased predictability of bone augmentation when performing this pre-orthodontic surgical technique. Critical surgery-related factors of SFOT that will be examined include incision and flap design and closure, the depth and location of corticotomies, surgical trauma, augmentation protocols, and postoperative considerations. Biomaterial-related factors that will be reviewed encompass bone grafting materials, biologics, barrier membranes, and planned tooth movement.

Surgical Considerations and Decision Making in Surgically Facilitated Orthodontic Treatment/Periodontally Accelerated Osteogenic Orthodontics.

FOCUSED CLINICAL QUESTION: Surgically facilitated orthodontic treatment (SFOT)/periodontally accelerated osteogenic orthodontics (PAOO) has the potential of allowing safer orthodontic treatment in vulnerable periodontium with thin phenotypes. SFOT/PAOO is a phenotype modification therapy (PhMT) approach where thin bone morphotype and/or gingiva are surgically augmented to convert a fragile-thin to a robust-thick periodontal environment. This permits orthodontic treatment in these previously thin phenotype cases to proceed without iatrogenically-induced adverse effects. This is an infrequently performed procedure with few available clinical recommendations. SUMMARY: In this practical application paper, three clinicians with the collective clinical experience of over 1500 SFOT cases developed a clinical decision-making algorithm outlining the key steps for SFOT. A sample case is provided for clinical appreciation of the procedure. Lastly, this panel reviewed and detailed the critical decision making and surgical approaches associated with the use of SFOT. Though the basic decision making is consistent, individual variations on surgical management are compared. This is summarized in a clinical decision tree along with a sample clinical case. Additionally, the cumulative experience has been organized into tables that provide comparative decision and surgical approaches. There are similarities and differences. Lastly, strategies that have not been individually effective are also noted. CONCLUSION: SFOT/PAOO is an effective PhMT approach whereby the bone and/or soft tissue phenotype can be surgically modified to permit orthodontic treatment in patients with thin phenotypes. The cumulative experience of three experienced clinicians provides clinical recommendations for SFOT management of PhMT for pre-orthodontic treatment.

Factors Affecting Predictability of Buccal Bone Augmentation in Surgically Facilitated Orthodontic Treatment: Etiological Considerations.

Pre-orthodontic surgical techniques such as surgically facilitated orthodontic treatment (SFOT) are intended to increase bone volume while reducing the incidence of induced gingival recession. SFOT aims to enhance and thicken the periodontal biotype, including both hard and soft tissue, and facilitate accelerated tooth movement through the induction of the regional acceleratory phenomenon. This article reviews different variables and critical etiological factors that may affect the predictability of generating buccal bone during SFOT and should be diagnosed and addressed prior to combined surgical-orthodontic treatment. In addition, optional modifications to enhance regenerative outcomes of SFOT will be discussed.

Enhancing Periodontal Regenerative Outcomes With Simultaneous Orthodontic Tooth Movement.

Periodontal regeneration of lost tissue, including periodontal ligament (PDL), cementum, and bone, has evolved with regard to surgical techniques, biomaterials, and growth factors. Simultaneous orthodontic therapy and periodontal surgical treatment has been documented previously and shown to enhance the regenerative outcome due to stimulation of the PDL by tooth movement. This combined strategy is becoming increasingly common as clinicians explore the capabilities of a collaborative approach. This article presents a case series that documents three cases in which combined orthodontic and surgical procedures were used to enhance the regenerative outcome in challenging clinical scenarios. The article includes a review of the literature and discusses clinical factors related to increasing predictability in such cases.

Dental Space Deficiency Syndrome: An Anthropological Perspective.

A new syndrome in dentistry, the dental space deficiency syndrome is proposed in this article. Signs and symptoms of this entity may include one or more of the following clinical dental features: tooth crowding, gingival recession, tooth impactions, rapid resorption of facial alveolar bony plates following premature tooth loss, dentally oriented sleep disorders, extended orthodontic treatment time, and malocclusion relapse following orthodontic therapy. These oral conditions, individually or collectively, seem to be associated with both genetic and functional factors. From an anthropological-functional perspective, the human jaws (basal bone and/or alveolar bone) have been shrinking. This results in a three-dimensional discrepancy between jawbone and tooth volumes, which are genetically determined. Consequently, the reduced volume of alveolar bone is not adequately able to accommodate the associated genetically determined dentition in functional and esthetic harmony. This paper describes the common etiology for the conditions listed above, namely the discrepancy between alveolar bone volume (essentially determined by functionality), and associated tooth volume (essentially determined by genetics), when considered in a three-dimensional perspective.

Is gingival recession a consequence of an orthodontic tooth size and/or tooth position discrepancy? "A paradigm shift".

BACKGROUND: Gingival recession (GR) is a commonly observed dental lesion. The underlying etiology has not been clearly identified, although several theories have been suggested. Tooth crowding or tooth malalignment is also frequently observed, with both conditions appearing to be more prevalent in developed countries with heterogeneous populations. MATERIALS AND METHODS: A total of 25 consecutively treated patients representing 72 teeth and demonstrating facial clinical GR of > 3 mm were examined clinically, photographically, and with 3-dimensional radiology using conebeam computed tomography. All examined teeth presented with normal interproximal probing depths and attachment levels (< 4 mm). Tooth position or tooth volume plus the associated adjacent alveolar bone volume and GR were analyzed. This group was further evaluated during periodontal surgery for associated alveolar bone fenestrations or dehiscences. RESULTS: All teeth demonstrating > 3 mm of GR presented with significantly prominent facial tooth contours and associated alveolar bone dehiscences. Most involved teeth presented with their root structures extending beyond the facial alveolar bony housing (fenestrations). This represents a discrepancy between tooth size and alveolar bone dimensions in the buccolingual, axial, and sagittal orientation. Fewer involved teeth were malpositioned toward the buccal aspect. Both conditions were associated with facial alveolar bone dehiscences and associated GR. CONCLUSIONS: This study suggests tooth volume and/or tooth position within the alveolar bony housing strongly correlate with GR. All nonperiodontitis-involved teeth with GR were associated with either wider teeth or facially aligned teeth. However, it is emphasized that all facially aligned teeth, or "larger" teeth, do not necessarily present with GR. Based on these findings, the radiographic-supporting bone index is proposed. This index should facilitate appropriate evaluation of the alveolar bone supporting the mucogingival complex, both on the facial and lingual aspect of teeth. Further investigations are needed to support these preliminary data.

Is gingival recession a consequence of an orthodontic tooth size and/or tooth position discrepancy? "A paradigm shift".

BACKGROUND: Gingival recession (GR) is a commonly observed dental lesion. The underlying etiology has not been clearly identified, although several theories have been suggested. Tooth crowding or tooth malalignment is also frequently observed, with both conditions appearing to be more prevalent in developed countries with heterogeneous populations. MATERIALS AND METHODS: A total of 25 consecutively treated patients representing 72 teeth and demonstrating facial clinical GR of > 3 mm were examined clinically, photographically, and with 3-dimensional radiology using cone-beam computed tomography. All examined teeth presented with normal interproximal probing depths and attachment levels (less than 4 mm). Tooth position or tooth volume plus the associated adjacent alveolar bone volume and GR were analyzed. This group was further evaluated during periodontal surgery for associated alveolar bone fenestrations or dehiscences. RESULTS: All teeth demonstrating > 3 mm of GR presented with significantly prominent facial tooth contours and associated alveolar bone dehiscences. Most involved teeth presented with their root structures extending beyond the facial alveolar bony housing (fenestrations). This represents a discrepancy between tooth size and alveolar bone dimensions in the buccolingual, axial, and sagittal orientation. Fewer involved teeth were malpositioned toward the buccal aspect. Both conditions were associated with facial alveolar bone dehiscences and associated GR. CONCLUSIONS: This study suggests tooth volume and/or tooth position within the alveolar bony housing strongly correlate with GR. All nonperiodontitis-involved teeth with GR were associated with either wider teeth or facially aligned teeth. However, it is emphasized that all facially aligned teeth, or "larger" teeth, do not necessarily present with GR. Based on these findings, the radiographic-supporting bone index is proposed. This index should facilitate appropriate evaluation of the alveolar bone supporting the mucogingival complex, both on the facial and lingual aspect of teeth. Further investigations are needed to support these preliminary data.