Cone Beam Computed Tomography Analysis of Posterior-Superior Alveolar Canal from a Fixed Reference Point: Implications for Sinus Floor Elevation Procedure through Lateral Approach.

Objective: Sinus floor elevation is commonly done in the maxillary posterior region prior to dental implant placement. This study primarily aimed at assessing the location of the posterior superior alveolar artery (PSAA) canal on cone beam computed tomography (CBCT) scans and its relation to the alveolar ridge and maxillary sinus from a fixed reference point. Material and Methods: A total of 226 edentulous maxillary molar sites were included in this retrospective analysis. The distance from the PSAA to the sinus floor (SF), alveolar crest (AC) and a fixed reference point, that is, the roof of sinus (RS) were measured. The alveolar bone height (ABH), thickness of the crestal keratinized mucosa (CKM) and thickness of Schneiderian membrane (SM) were also evaluated. Results: 54 sites (23.89%) were excluded from the study. The SF, AC, RS and ABH values averaged at 11.91 mm ± 3.63 mm, 16.05 mm ± 3.96 mm, 25.32 mm ± 7.13 mm and 4.93 mm ± 4.27 mm respectively. SF and AC was higher in second molar than first molar region (p < 0.001), but RS did not show significant difference (p = 0.85). CKM and SM averaged at 2.02 mm ± 0.68 mm and 1.31 mm ± 0.81 mm respectively. Conclusion: The PSAA can be visualized in CBCT scans with a prevalence of 76.11% and may not be detected when adherent to the sinus membrane. This study stresses on the need for a CBCT, prior to sinus surgeries through lateral approach, to assess the PSAA.

High Mortality After Total Knee Arthroplasty Periprosthetic Joint Infection is Related to Preoperative Morbidity and the Disease Process but Not Treatment.

BACKGROUND: Periprosthetic joint infection (PJI) mortality rate is approximately 20%. The etiology for high mortality remains unknown. The objective of this study was to determine whether mortality was associated with preoperative morbidity (frailty), sequalae of treatment, or the PJI disease process itself. METHODS: A multicenter observational study was completed comparing 184 patients treated with septic revision total knee arthroplasty (TKA) to a control group of 38 patients treated with aseptic revision TKA. Primary outcomes included time and the cause of death. Secondary outcomes included preoperative comorbidities and Charlson Comorbidity Index (CCMI) measured preoperatively and at various postoperative timepoints. RESULTS: The septic revision TKA cohort experienced earlier mortality compared to the aseptic cohort, with a higher mortality rate at 90 days, 1, 2, and 3 years after index revision surgery (P = .01). There was no significant difference for any single cause of death (P > .05 for each). The mean preoperative CCMI was higher (P = .005) in the septic revision TKA cohort. Both septic and aseptic cohorts experienced a significant increase in CCMI from the preoperative to 3 years postoperative (P < .0001 and P = .002) and time of death (P < .0001 both) timepoints. The septic revision TKA cohort had a higher CCMI 3 years postoperatively (P = .001) and at time of death (P = .046), but not one year postoperatively (P = .119). CONCLUSION: Compared to mortality from aseptic revision surgery, septic revision TKA is associated with earlier mortality, but there is no single specific etiology. As quantified by changes in CCMI, PJI mortality was associated with both frailty and the PJI disease process, but not treatment.

A Clinical Guide for Treatment of Dental Cervical Lesions Through a Restorative, Surgical, or Combination Approach: A Proposed Evidence-Based Algorithm.

The incidence of dental cervical carious and noncarious lesions is common, and often these are treated with a restorative material without due attention paid to the amount of exposed cementum/enamel, level of interproximal bone, and final desired esthetic result. This article is intended to provide clinicians an evidence-based clinical decision tree for treating such lesions through a restorative, surgical, or combination approach such that the optimum functional and cosmetic result is achieved.

Long-term evaluation (7 years) of coronally advanced flap with (CAF) and without (e-CAF) vertical release incisions using a subepithelial connective tissue graft in the treatment of multiple recession-type defects.

OBJECTIVES: The objective of this retrospective study was to compare the 7-year outcomes of coronally advanced flap with vertical incisions (CAF) and the envelope type of flap (e-CAF), using a subepithelial connective tissue graft (SCTG) in the treatment of multiple recession defects. METHOD AND MATERIALS: Twenty-two patients (13 CAF and 9 e-CAF) with at least two adjacent recession defects in the esthetic zone contributed to a total of 50 sites (29 CAF and 21 e-CAF). Complete root coverage (CRC), mean root coverage (MRC), and keratinized tissue (KT) width were recorded over the course of the study. RESULTS: In the short term (8 months), CRC, MRC, and KT outcomes were similar between the groups (P > .05). However, at the 3-year follow-up, the e-CAF group displayed significantly higher KT, MRC (100%), and CRC (100% at both tooth- and patient-levels) than the CAF group (MRC 91.43%; CRC 79.31% at tooth-level and 69.23% at patient-level). Similarly, at the 7-year follow-up, statistically significantly superior KT, MRC (94.24%), and CRC (87.71% at tooth-level and 77.78% at patient-level) values were recorded for the e-CAF group compared to the CAF group (MRC 68.98%; CRC 31.03% at tooth-level and 15.38% at patient-level). CONCLUSIONS: Despite similar treatment outcomes recorded by both surgical procedures in the short term, sites treated with e-CAF showed better stability of the gingival margin and superior KT width in the medium (3 years) and long term (7 years).

The Graft Infusion Technique (GIT) for Treatment of Peri-Implantitis Defects: Case Series.

Peri-implantitis is a site-specific infectious disease that causes an inflammatory process in soft tissues, and bone loss around an osseointegrated implant in function. Several techniques with non-surgical or surgical debridement and decontamination followed by ongoing supportive therapy or regeneration of the peri-implant bone defects have been proposed in the literature. However, the literature is still unclear on an effective protocol for implant surface decontamination or the appropriate choice of regenerative materials. This case series describes a surgical technique to treat peri-implantitis osseous defects using a mixture of deproteinized bovine bone mineral with 10% porcine collagen (DBBM-C) in a block form, soaked in an appropriate antibiotic. The use of this combination provides advantages such as good graft adaptability along with localized antibiotic release without the use of systemic antibiotics. Thus, this technique might be an effective method to treat amenable peri-implantitis defects. Additionally, the proposed algorithm also allows for customized culture based antibiotic loading. To the best of the authors' knowledge, this is the first case series documenting this technique for peri-implantitis defects. Long-term studies with controlled samples would be necessary for further evaluation.

Evaluating Mouse Fibroblast Interaction with Implant Surfaces in a 3D Microenvironment.

PURPOSE: Previous studies assessing fibroblast interactions with implants have mainly relied on measurements such as cell migration, gene expression, and cell adhesion. For these studies, testing cellular behavior at the implant surface was done by imaging the cell-implant interface using standard microscopy techniques in 2D tissue culture dishes. The true behavior of cells relative to the implant can best be assessed in a more physiologic 3D microenvironment. MATERIALS AND METHODS: The embedding of the implant disks in 3D collagen gels was standardized with labeled fibroblasts to allow the imaging of fibroblast morphology and behavior when proximal to or binding to the implant disks. This allowed comparison of the behavior of laser-microgrooved and machined implant disk surfaces quantitatively in an in vitro 3D microenvironment. RESULTS: This in vitro imaging assay revealed for the first time in a 3D microenvironment setting the statistically significant impact laser-microgrooved disk surfaces have on both cell adherence and recruitment of cells in proximity to the disk. It also allowed visualization of membrane protrusivity and cytoskeletal organization in cells adherent to the implant disk. CONCLUSION: This assay provides a simple and effective way of observing cell behavior on and around the implant disk surface in a more physiologic 3D setting. Within the limits of this study, it revealed that the laser-microgrooved implant surface demonstrates significant superiority in fibroblast recruitment and binding in a 3D microenvironment.

Synthesis, Quantification, and Characterization of Fatty Acid Amides from In Vitro and In Vivo Sources.

Fatty acid amides are a diverse family of underappreciated, biologically occurring lipids. Herein, the methods for the chemical synthesis and subsequent characterization of specific members of the fatty acid amide family are described. The synthetically prepared fatty acid amides and those obtained commercially are used as standards for the characterization and quantification of the fatty acid amides produced by biological systems, a fatty acid amidome. The fatty acid amidomes from mouse N18TG2 cells, sheep choroid plexus cells, Drosophila melanogaster, Bombyx mori, Apis mellifera, and Tribolium castaneum are presented.

Risk Factors, Screening, and Treatment Challenges in Staphylococcus aureus Native Septic Arthritis.

BACKGROUND: Staphylococcus aureus is the most common cause of native septic arthritis. Few studies have characterized this disease during the US opioid epidemic. The role of methicillin-resistant Staphylococcus aureus (MRSA) nasal screening in this disease has not been elucidated. We sought to identify risk factors and outcomes for S. aureus native septic arthritis and to evaluate MRSA screening in this disease. METHODS: A retrospective cohort study of native septic arthritis patients (2012-2016) was performed. Demographics, risk factors, and outcomes were compared between Staphylococcus aureus and other native septic arthritis infections. Sensitivity, specificity, and predictive values of MRSA screening were assessed. RESULTS: Two hundred fifteen cases of native septic arthritis were included. S. aureus was cultured in 64% (138/215). MRSA was cultured in 23% (50/215). S. aureus was associated with injection drug use (odds ratio [OR], 4.33; 95% CI, 1.74-10.81; P = .002) and switching antibiotics (OR, 3.92; 95% CI, 1.01-21.38; P = .032). For every 10-year increase in age, the odds of S. aureus decreased (OR, 0.72; 95% CI, 0.60-0.87; P = .001). For 1-unit increases in Charlson comorbidity index score, the odds of S. aureus decreased (OR, 0.82; 95% CI, 0.73-0.91; P = .0004). MRSA screening during admission demonstrated a sensitivity of 0.59, specificity of 0.96, positive predictive value of 0.85, and negative predictive value of 0.84 for MRSA native septic arthritis. CONCLUSIONS: The opioid epidemic may be contributing to a demographic shift in native septic arthritis to younger, healthier individuals. S. aureus native septic arthritis has unique risks, including injection drug use. MRSA screening may be useful to rule in MRSA native septic arthritis.

Staphylococcus epidermidis Biofilms Have a High Tolerance to Antibiotics in Periprosthetic Joint Infection.

Both Staphylococcus aureus and Staphylococcus epidermidis are commonly associated with periprosthetic joint infections (PJIs). The treatment of PJI can be challenging because biofilms are assumed to have an increased intolerance to antibiotics. This makes the treatment of PJI challenging from a clinical perspective. Although S. aureus has been previously demonstrated to have increased biofilm antibiotic tolerance, this has not been well established with Staphylococcus epidermidis. A prospective registry of PJI S. epidermidis isolates was developed. The efficacy of clinically relevant antibiotics was quantified against these isolates. S. epidermidis planktonic minimum inhibitory concentration (MIC) and minimum bactericidal concentration (MBC) were collected using clinical laboratory standard index (CLSI) assays for eight antibiotics (doxycycline, vancomycin, daptomycin, clindamycin, rifampin, nafcillin, and trimethoprim/sulfamethoxazole). Mature biofilms were grown in vitro, after which minimum biofilm inhibitory concentration (MBIC) and minimum biofilm bactericidal concentration (MBBC) were quantified. Only rifampin and doxycycline had a measurable MBIC across all tested isolates. Based on MBBC, 64% of S. epidermidis biofilms could be eliminated by rifampin, whereas only 18% by doxycycline. S. epidermidis biofilm was observed to have a high tolerance to antibiotics as compared to planktonic culture. Isolate biofilm antibiotic tolerance varied to a larger degree than was seen in planktonic cultures.

Three-Dimensional Alveolar Bone Assessment of Mandibular First Molars with Implications for Immediate Implant Placement.

The aim of this retrospective study was to evaluate the alveolar dimensions of the mandibular molar using cone beam computed tomography (CBCT) for immediate implant placement. The width of buccal (WB) and lingual (WL) bone; width of interradicular bone 2 and 4 mm apical to the furcation and at the apex (IRB2, IRB4, and IRBA, respectively); and distance to the inferior alveolar nerve from the furcation (IAN-F) and mesial (IAN-M) and distal (IAN-D) roots were evaluated from CBCT records of 126 subjects (200 mandibular first molars). Mean WB (0.84 ± 0.39 mm) and WL (2.71 ± 1.17 mm) measurements showed significant differences (P = .003). Differences between IAN-F, IAN-M, and IAN-D measurements averaged at 14.14 ± 2.57 mm, 4.31 ± 1.06 mm, and 4.61 ± 1.02 mm, respectively. IRB2, IRB4, and IRBA dimensions were 1.93 ± 0.65 mm, 2.54 ± 0.9 mm, and 4.46 ± 1.91 mm, respectively. The findings of the study demonstrate the alveolar bone morphology of the mandibular first molar and the need for CBCT scans for proper treatment planning for immediate implant placement.

Administration of Tranexamic Acid Improves Long-Term Outcomes in Total Knee Arthroplasty.

BACKGROUND: Blood transfusion in total knee arthroplasty (TKA) is associated with increased morbidity, including periprosthetic joint infection (PJI). Tranexamic acid (TXA) reduces blood transfusion rates, but there is limited evidence demonstrating improved outcomes in TKA resulting from TXA administration. The objectives of this study are determining whether TXA is associated with decreased rate of PJI, decreased rate of outcomes associated with PJI, and whether there are differences in rates of adverse events. METHODS: A multicenter cohort study comprising 23,421 TKA compared 4423 patients receiving TXA to 18,998 patients not receiving TXA. Primary outcome was PJI within 2 years of TKA. Secondary outcomes included revision surgery, irrigation and debridement, transfusion, and length of stay. Adverse events included readmission, deep vein thrombosis, pulmonary emboli, myocardial infarction, or stroke. Adjusted odds ratios were determined using linear mixed models controlling for age, sex, thromboembolic prophylaxis, Charlson comorbidity index, year of TKA, and surgeon. RESULTS: TXA administration reduced incidence of PJI by approximately 50% (odds ratio [OR], 0.55; P = .03). Additionally, there was decreased incidence of revision surgery at 2 years (OR, 0.66; P = .02). Patients receiving TXA had reductions in transfusion rate (OR, 0.15; P < .0001) and length of stay (P < .0001). There was no difference in the rate of pulmonary emboli (OR, 1.20; P = .39), myocardial infarction (OR, 0.78; P = .55), or stroke (OR, 1.17; P = .77). CONCLUSION: Administration of TXA in TKA resulted in reduced rate of PJI and overall revision surgery. No difference in thromboembolic events were observed. The use of TXA is safe and improves outcomes in TKA. LEVEL OF EVIDENCE: Level III, Observational Cohort Study.

In Vitro Surface Testing Methods for Dental Implants-Interpretation and Clinical Relevance: A Review.

More than 2,000 dental implant options are estimated to be available for any given clinical situation. Because many implants have claims that are substantiated mainly on the basis of in vitro studies, it is prudent for clinicians to understand the interpretation of such studies and possible clinical relevance. In vitro tests can be segregated as surface analysis tests and mechanical assessment tests. With a wide variation of methodologies used and results achieved by different implant manufacturers, practitioners may find it difficult to judge the clinical significance of in vitro tests. This article provides an overview, including limitations, of the in vitro implant analysis tests implant companies routinely perform, ranging from older methods involving mechanical testing and surface microscopy to more recent tests such as atomic force microscopy (AFM) studies and gene expression tests, to assist clinicians when choosing an implant system. Having identified the limitations of in vitro testing methods, the current evidence indicates that scanning electron microscopy may be useful in providing insight on the role of implant surface topography. AFM, single cell tests, 3D imaging, and gene expression tests could be useful for assessment of cellular and physio-biochemical properties. 3D finite element analysis may help in the evaluation of mechanical properties of dental implants. Clinicians are encouraged to correlate the findings of in vitro tests with robust animal histologic studies and well-designed, high-quality clinical research to ascertain optimum clinical results.

Quantitative Assessment of the Edentulous Posterior Maxilla for Implant Therapy: A Retrospective Cone Beam Computed Tomographic Study.

AIM: Dimensional changes of the alveolar bone are often noted in horizontal and vertical planes as a sequel to tooth extraction, particularly in the maxillary posterior region due to alveolar bone resorption combined with pneumatization of the sinus. The aim of this retrospective study was to quantitatively assess the maxillary residual alveolar ridge using cone beam computed tomography (CBCT) scans. MATERIALS AND METHODS: A total of 349 edentulous sites from 250 CBCTs were evaluated. The apico-coronal bone height and bucco-palatal crest width were measured in sagittal and coronal slices, respectively. Additionally, the obliqueness of the sinus floor at the edentulous sites was also evaluated. RESULTS: One hundred and twelve (55.45%) of the molar and 74 (54.42%) of the premolar sites had a horizontal ridge dimension < 6 mm, whereas 137 (67.83%) of the molar and 61 (44.86%) of the premolar sites showed an apico-coronal height < 8 mm. Furthermore, 183 (54.14%) of the evaluated sites had an oblique sinus floor morphology. CONCLUSION: Additional augmentative procedures are thus required in a high percentage of the population at the edentulous maxillary posterior site for rehabilitation using a standard dimension implant. This study stresses on the need for a three-dimensional CBCT prior to implant surgery for proper treatment planning.

Benefits and Adverse Events Associated With Extended Antibiotic Use in Total Knee Arthroplasty Periprosthetic Joint Infection.

BACKGROUND: Total knee arthroplasty (TKA) periprosthetic joint infection (PJI) can be managed with debridement, antibiotic therapy, and implant retention (DAIR). Oral antibiotics can be used after DAIR for an extended time period to improve outcomes. The objective of this study was to compare DAIR failure rates and adverse events between an initial course of intravenous antibiotic therapy and the addition of extended treatment with oral antibiotics. METHODS: A multicenter observational study of patients diagnosed with a TKA PJI who underwent DAIR was performed. The primary outcome of interest was the failure rate derived from the survival time between the DAIR procedure and future treatment failure. RESULTS: One hundred eight patients met inclusion criteria; 47% (n = 51) received an extended course of oral antibiotics. These patients had a statistically significant lower failure rate compared to those who received only intravenous antibiotics (hazard ratio, 2.47; P = .009). Multivariable analysis demonstrated that extended antibiotics independently predicted treatment success, controlling for other variables. There was no significant difference in failure rates between an extended course of oral antibiotics less or more than 12 months (P = .23). No significant difference in the rates of adverse events was observed between patients who received an initial course of antibiotics alone and those who received a combination of initial and extended antibiotic therapy (P = .59). CONCLUSIONS: Extending therapy with oral antibiotics had superior infection-free survival for TKA PJI managed with DAIR. There was no increase in adverse events, demonstrating safety. After 1 year, there appears to be no significant benefit associated with continued antibiotic therapy.

Osseodensification -- A systematic review and qualitative analysis of published literature.

The recently introduced technique of osseodensification for dental implant involves the use of special drills (Densah) run in a counter-clockwise direction at the osteotomy site. It is claimed that this causes expansion of the osteotomy site, and increases density of the bone in immediate vicinity of the osteotomy. We reviewed published papers on the primary stability attained using this drilling technique. As a secondary finding, the bone to implant contact (BIC) and the bone area fraction occupancy (BAF) was also compared between the conventional drilling protocol and the osseodensification protocol, among these articles. A Systematic search was performed in PubMed-Medline, Embase and Google Scholar for clinical/animal studies up to November 2018. A total of 12 articles, from a database of 132 articles, consisting of 8 animal histologic studies, 2 human based clinical studies, 1 case series and 1 case report were assessed. 10/12 articles measured the insertion torque values, 7/12 articles measured the BIC and 6/12 articles estimated the BAF between the two techniques. Quality assessment of 8 studies performed using ARRIVE guidelines showed that 6/8 studies had a high score. An average increase in the insertion torque, BIC and BAF was noted in the osseodensification group as compared to the conventional drilling group. Since most of these studies are non-clinical, it can be inferred that osseodensification is an efficient way to enhance primary stability of implants in low density bone in an animal model. However, extrapolation to long term clinical success cannot be ascertained until further evidence becomes available.