Efficacy of communicating periodontal risk on psychological outcomes and supragingival plaque control in patients undergoing first periodontal consultation: A parallel-arm, randomized trial.

AIM: To evaluate the efficacy of the PerioRisk prognostic tool in implementing the effect of motivational interviewing (MI) on psychological outcomes and supragingival plaque control. MATERIALS AND METHODS: Participants underwent MI immediately after their first periodontal visit. According to a parallel-arm, randomized study design, MI was performed with (RISK group) or without (CTR group) information on PerioRisk level and treatment goals based on PerioRisk output. Psychological outcomes were assessed using the Positive Affect Negative Affect Scale (PANAS) and Protection Motivation Theory (PMT). Plaque index (PI) was re-evaluated after 8-12 weeks. RESULTS: Significant improvements in PMT overall score and PI were observed in CTR and RISK groups, without inter-group difference in PANAS and PMT overall scores and PI. A sub-analysis showed that the overall PMT scores recorded immediately after MI in both CTR and RISK groups for subjects with no tooth loss due to periodontitis were higher than those recorded before MI in subjects with tooth loss due to periodontitis. CONCLUSIONS: At first periodontal visit, MI (implemented with without PerioRisk) has tangible effects on psychological outcomes and supragingival plaque control and seems to anticipate the awareness that is commonly generated by periodontitis-related tooth loss (ClinicalTrials.gov protocol registration ID: NCT05078411).

Factors affecting radiographic marginal bone resorption at dental implants in function for at least 5 years: A multicenter retrospective study.

OBJECTIVE: To evaluate the influence of patient and implant-related factors on the changes of marginal bone levels (MBL) at implants with a follow-up ≥5 years. MATERIALS AND METHODS: At baseline (within 6 months from prosthetic insertion) and long-term (≥5 years after implant placement) visits, interproximal (mesial and distal) MBL were radiographically evaluated. To analyze factors predicting MBL change, the site (either mesial or distal) showing the highest MBL change (hChMBL site) was identified for each implant. Multilevel regression models were built to explain MBL change as well as the probability for a bone loss ≥2 mm at long-term. RESULTS: 942 implants in 312 patients with a mean follow-up of 8.02 ± 2.5 years were analyzed. MBL change was significantly predicted by baseline MBL, oral bisphosphonate (BP) intake, history of periodontitis, diabetes, and super-hydrophilic implant surface. Higher risk for a bone loss ≥2 mm was observed in patients with history of periodontitis (OR = 9.52, 95% CI 0.72-3.79) and taking BP (OR = 6.84, 95% CI 0.21-3.63). Mandibular implants had higher odds for bone loss ≥2 mm compared to maxillary implants (OR = 3, 95% CI 0.39-1.87). CONCLUSIONS: The findings of the present study contribute to the identification of specific clinical scenarios at higher risk for implant-supporting bone loss that need to be strictly monitored during maintenance.

Minimal invasiveness in the transcrestal elevation of the maxillary sinus floor: A systematic review.

In the attempt to reduce the invasiveness of a transcrestal sinus floor elevation procedure, different aspects must be considered; that is, the minimization of intra- and postsurgery morbidity, the reduction of treatment time, and the simplification/elimination of the reconstructive technology. Within this context, a systematic literature search was performed for controlled clinical trials evaluating the impact of one or more of these aspects on transcrestal sinus floor elevation invasiveness. Nineteen articles (15 studies) were included. Overall, the results confirmed that transcrestal sinus floor elevation is a minimally invasive and effective option for bone augmentation in the edentulous, atrophic posterior maxilla. By using powered instruments rather than manual osteotomes and hand mallet, the invasiveness of transcrestal sinus floor elevation can be further reduced without affecting its clinical effectiveness. To impact effectively on morbidity, the key elements to consider when selecting instruments for transcrestal sinus floor elevation are (a) their availability as a standardized sequence, to be adapted on predetermined residual bone height, and (b) the possibility to control pressure (eg, with screwable osteotomes) and/or instrument excursion (eg, with stop devices) to fracture the maxillary sinus floor. Among powered instruments, a standardized sequence of drills incorporating a trephine drill seem to be particularly indicated, due to reduced chair time, high tolerability for the patient, and the possibility to isolate a bone core to implement histomorphometric outcomes. At molar extraction sites with an interradicular septum characterized by a height of at least 4 mm, immediate transcrestal sinus floor elevation and implant placement can be considered a valid option to shorten treatment time.

Accuracy and applicability of periodontitis risk assessment tools: A critical appraisal.

Currently, periodontal risk assessment finds application at first visit (to identify individuals at high risk of either disease incidence, if still healthy, or disease progression, if already diseased) as well as at patient monitoring after active treatment and enrolment in a supportive periodontal care program. Although the current case definition of periodontitis embeds a prognostic determination (ie, periodontitis grade) that showed a predictive value for periodontitis-related tooth loss, some limitations of periodontitis grade call for the implementation of different risk assessment tools in clinical practice. For some of these, significantly higher accuracy in predicting tooth loss during supportive periodontal care was reported compared with periodontitis grade. Validated periodontal risk assessment tools may be functional to obtain greater adherence to the suggested preventive and treatment protocols, improve oral hygiene performance, and tailor supportive periodontal care. Interestingly, periodontal risk can also be informative of the risk of peri-implantitis in patients programmed for implant placement or rehabilitated with dental implants. A critical appraisal on the rationale behind risk assessment and the balance between the advantages and limitations of exercising risk assessment in periodontology is presented.

Minimal invasiveness in the surgical treatment of intraosseous defects: A systematic review.

The modern approach to regenerative treatment of periodontal intraosseous defects should aim at maximizing the clinical outcomes while minimizing the invasiveness (pain, complications, aesthetic impairment, chair time, and costs) of the procedure. The present systematic review evaluated the effect of flap design, regenerative technology, and perioperative and postoperative adjunctive protocols on invasiveness. Overall, the results of the 13 included trials indicate that: (a) the elevation of a single (buccal or lingual) flap positively influences the intensity of postoperative pain and improves the quality of early wound healing compared with double flaps; (b) while the adjunctive use of a membrane is associated with significantly longer surgery-related chair time and higher postoperative pain, the adjunctive use of enamel matrix derivative at sites receiving a graft significantly reduces postoperative pain; also, graft materials showed no significant impact on invasiveness; (c) open flap debridement performed through the elevation of a single flap may lead to substantial clinical improvements of the lesion with reduced surgery-related chair time and costs, thus representing a promising alternative to regenerative treatment. However, for such an approach, a histological evaluation of the nature of the reconstructed tissues is still lacking, and the presurgery conditions (eg, probing depth, defect severity, and defect morphology), which may benefit in terms of invasiveness, have not yet been defined; and (d) intraoperative and postoperative low-level laser biostimulation of the defect site may favorably modulate the postoperative course.

Minimal invasiveness in lateral bone augmentation with simultaneous implant placement: A systematic review.

The presence of a peri-implant bone dehiscence (BD) or fenestration (BF) is a common finding after implant placement in a crest with a reduced bucco-lingual bone dimension. The presence of a residual BD is associated with a relevant incidence of peri-implant biological complications over time. Guided bone regeneration (GBR), performed at implant placement, is the most validated treatment to correct a BD. In the present systematic review, the evidence evaluating factors which could reduce the invasiveness of a GBR procedure with respect to patient-reported outcomes, intra- and post- surgical complications, was summarized. Factors included were: technical aspects, regenerative materials for GBR, and peri- and post-operative pharmacological regimens. The available evidence seems to indicate that the use of membrane fixation and flap passivation by means of a double flap incision technique may reduce the incidence of post-surgical complications. When feasible, the coronal advancement of the lingual flap is suggested. The use of a non-cross linked resorbable membrane positively impacts on patient discomfort. The adjunctive use of autogenous bone to a xenograft seems not to improve BD correction, but could increase patient discomfort. Systemic antibiotic administration after a GBR procedure does not seem to be justified in systemically healthy patients.

Six-year extension results of a randomized trial comparing transcrestal and lateral sinus floor elevation at sites with 3-6 mm of residual bone.

OBJECTIVES: To comparatively evaluate the 6-year outcomes of transcrestal and lateral sinus floor elevation (tSFE and lSFE, respectively). METHODS: The 54 patients representing the per-protocol population of a randomized trial comparing implant placement with simultaneous tSFE versus lSFE at sites with a residual bone height of 3-6 mm were invited to participate in the 6-year follow-up visit. Study assessments included: peri-implant marginal bone level at the mesial (mMBL) and distal (dMBL) aspects of the implant, proportion of the entire implant surface in direct contact with the radiopaque area (totCON%), probing depth, bleeding on probing, suppuration on probing, and modified plaque index. Also, the conditions of the peri-implant tissues at 6-year visit were diagnosed according to the case definitions of peri-implant health, mucositis, and peri-implantitis from the 2017 World Workshop. RESULTS: Forty-three patients (21 treated with tSFE and 22 treated with lSFE) participated in the 6-year visit. Implant survival was 100%. At 6 years, totCON% was 96% (IR: 88%-100%) in tSFE group and 100% (IR: 98%-100%) in lSFE group (p = .036). No significant intergroup difference in patient distribution according to the diagnosis of peri-implant health/disease was observed. Median dMBL was 0.3 mm in tSFE group and 0 mm in lSFE group (p = .024). CONCLUSIONS: At 6 years following placement concomitantly with tSFE and lSFE, implants showed similar conditions of peri-implant health. Peri-implant bone support was high in both groups and was slightly but significantly lower in tSFE group.

Peri-implant tissue conditions following transcrestal and lateral sinus floor elevation: 3-year results of a bi-center, randomized trial.

OBJECTIVES: The present study was performed to comparatively evaluate the peri-implant bone stability and conditions of marginal tissues at 3 years following transcrestal and lateral sinus floor elevation (tSFE and lSFE, respectively). MATERIALS AND METHODS: Patients included in a parallel-arm randomized trial comparatively evaluating tSFE and lSFE were recalled at 3 years post-surgery. Twenty-one and 24 patients in tSFE and lSFE groups, respectively, participated in the follow-up visit. Peri-implant bone support was evaluated as the proportion of the entire implant surface in direct contact with the radiopaque area (totCON%) on 3-year periapical radiographs. The conditions of the marginal peri-implant tissues at 3-year visit were classified as peri-implant health, peri-implant mucositis, or peri-implantitis. RESULTS: At 3 years, both groups showed an implant survival rate of 100%. Median totCON% was stable at 3 years, being 100% in both groups (p = 0.124). Peri-implant health and mucositis were diagnosed in 10 (47.6%) and 11 (52.4%) patients, respectively, in the tSFE group, and in 8 (33.3%) and 16 (66.7%) subjects, respectively, in the lSFE group (p = 0.502). CONCLUSIONS: At 3 years following surgery, implants placed concomitantly with tSFE and lSFE fully maintain peri-implant bone support. Peri-implant mucositis was the most prevalent condition, with a similar prevalence between groups. CLINICAL RELEVANCE: Based on 3-year data on peri-implant bone support and prevalence of peri-implant diseases, the study suggests that tSFE and lSFE represent two equally valid options for the rehabilitation of the posterior maxilla. CLINICALTRIALS: gov ID: NCT02415946.

No benefit of an adjunctive phototherapy protocol in treatment of periodontitis: A split-mouth randomized controlled trial.

AIM: To assess the efficacy of a commercially available adjunctive phototherapy protocol ("Perio-1") in treatment of periodontitis. MATERIALS AND METHODS: In an examiner-blind, randomized, controlled, split-mouth, multicentre study, 60 periodontitis patients received root surface debridement (RSD) in sextants either alone (control sextants) or with the adjunctive phototherapy protocol (test sextants). Re-evaluation was performed at 6, 12 and 24 weeks. RESULTS: No statistically significant differences in mean (± standard deviation) clinical attachment level (CAL) change from baseline to week 24 were observed between test (-1.00 ± 1.16 mm) and control sextants (-0.87 ± 0.79 mm) at sites with probing pocket depths (PPDs) ≥5 mm ("deep sites") at baseline (p = .212). Comparisons between test and control sextants for all other parameters (CAL change at all sites, PPD change at deep sites/all sites, bleeding on probing, plaque scores), and for all change intervals, failed to identify any statistically significant differences. CONCLUSIONS: The phototherapy protocol did not provide any additional clinical benefits over those achieved by RSD alone. (German Clinical Trials Register DRKS00011229).

Single flap approach with or without enamel matrix derivative in the treatment of severe supraosseous defects: a retrospective study.

AIM: To comparatively evaluate the clinical effectiveness of the single flap approach (SFA) with and without enamel matrix derivative (EMD) in the treatment of supraosseous defects (SDs) associated with deep pockets. MATERIALS AND METHODS: Twenty patients, each contributing one SD associated with a deep (≥ 6 mm) pocket and treated with buccal SFA either alone (SFA group; n = 10) or in combination with EMD (SFA+EMD group; n =10), were retrospectively selected. Clinical parameters (probing depth, PD; clinical attachment level, CAL; gingival recession, REC) had been assessed at pre-surgery and 12 months post-surgery. RESULTS: Complete wound closure was observed in 70% and 80% of defects treated with SFA and SFA+EMD, respectively. Treatments resulted in a significant PD reduction of 3.1±1.0 mm (p=0.005). In SFA+EMD group, 100% of closed pockets was obtained, while 90% of closed pockets was observed in SFA group. Both treatments resulted in a significant CAL gain of 2.1±0.9 mm and 1.9±1.7 mm in SFA and SFA+EMD group, respectively (p= 0.465). In both groups, REC significantly increased 1.0±1.1 mm in SFA group and 1.1±1.1 mm in SFA+EMD group (p= 0.722). CONCLUSIONS: Within their limits, the findings of present study suggest that SFA may represent a valuable option for the surgical treatment of SDs associated with deep pockets. EMD did not result in a significant clinical benefit to the procedure. CLINICAL RELEVANCE: SFA may represent a valuable option in obtaining pocket closure when treating SDs associated with deep residual pockets.

Tooth loss in complying and non-complying periodontitis patients with different periodontal risk levels during supportive periodontal care.

OBJECTIVES: To evaluate yearly tooth loss rate (TLR) in periodontitis patients with different periodontal risk levels who had complied or not complied with supportive periodontal care (SPC). MATERIALS AND METHODS: Data from 168 periodontitis patients enrolled in a SPC program based on a 3-month suggested recall interval for at least 3.5 years were analyzed. For patients with a mean recall interval within 2-4 months ("compliers") or > 4 months ("non-compliers") with different PerioRisk levels (Trombelli et al. 2009), TLR (irrespective of the cause for tooth loss) was calculated. TLR values were considered in relation to meaningful TLR benchmarks from the literature for periodontitis patients either under SPC (0.15 teeth/year; positive benchmark) or irregularly complying with SPC (0.36 teeth/year; negative benchmark). RESULTS: In both compliers and non-compliers, TLR was significantly below or similar to the positive benchmark in PerioRisk level 3 (0.08 and 0.03 teeth/year, respectively) and PerioRisk level 4 (0.12 and 0.18 teeth/year, respectively). Although marked and clinically relevant in non-compliers, the difference between TLR of compliers (0.32 teeth/year) and non-compliers (0.52 teeth/year) with PerioRisk level 5 and the negative benchmark was not significant. CONCLUSION: A SPC protocol based on a 3- to 6-month recall interval may effectively limit long-term tooth loss in periodontitis patients with PerioRisk levels 3 and 4. A fully complied 3-month SPC protocol seems ineffective when applied to PerioRisk level 5 patients. CLINICAL RELEVANCE: PerioRisk seems to represent a valid tool to inform the SPC recall interval as well as the intensity of active treatment prior to SPC enrollment.

What periodontal recall interval is supported by evidence?

Recall sessions are an integral part of supportive periodontal therapy. The aim of the current article is to review the existing evidence to support if and to what extent a predefined frequency of periodontal recall sessions ensures periodontal health and stability. Factors that potentially affect the time interval for recall are described. Moreover, original data on the relevance of residual diseased sites (ie, bleeding pockets) at patient level to predict the progression of periodontitis are presented. Overall, wide heterogeneity was found in the published literature with regards to the proposed supportive periodontal therapy recall frequency once active periodontal therapy has been completed. Available data clearly show that a primary and secondary preventive regimen based on routine supportive periodontal therapy is beneficial to preserve a periodontally healthy dentition and prevent tooth loss. However, convincing evidence regarding the appropriateness, risk-benefit, and cost-effectiveness of different recall intervals is currently scarce. In patients affected by moderate to advanced periodontitis, a supportive periodontal therapy protocol based on a 2-4 month recall interval appears reasonable. Limited data suggest that the amount/proportion of residual diseased sites (intended as pockets or bleeding pockets) and risk assessment tools may be of value in establishing the appropriate recall frequency.

Peri-implant tissue conditions at implants treated with Sub-periosteal Peri-implant Augmented Layer technique: A retrospective case series.

OBJECTIVES: To assess peri-implant tissue conditions on the short term in patients receiving the Sub-periosteal Peri-implant Augmented Layer (SPAL) technique and in patients with adequate thickness (≥2 mm) of the peri-implant buccal bone plate (PBBP) at placement. METHODS: Patients where either a dehiscence defect or thin PBBP at implant placement was corrected by SPAL technique (SPALdehiscence and SPALthin groups, respectively) and patients presenting a residual PBBP thickness ≥2 mm at implant placement (control group) were retrospectively selected. The number of peri-implant sites positive to bleeding on probing (BoP) at 6 months following prosthetic loading was the primary outcome. Also, height of keratinized mucosa, marginal soft tissue level, Plaque Index, peri-implant probing depth, suppuration on probing, and interproximal radiographic bone level (RBL) were evaluated. RESULTS: Thirty-four patients (11 in the SPALdehiscence group, 11 in the SPALthin group, and 12 in the control group) were included. In each SPAL group, 10 patients (90.9%) showed peri-implant tissue thickness ≥2 mm at the most coronal portion of the implant at uncovering. The prevalence (number) of BoP-positive sites was 2, 1, and 0 in the SPALdehiscence , SPALthin , and control groups, respectively. RBL amounted to 0.3 mm in the SPALdehiscence group, 0.2 mm in the SPALthin group, and 0 mm in the control group. CONCLUSION: After 6 months of prosthetic loading, patients treated with SPAL technique show limited peri-implant mucosal inflammation in association with shallow PD and adequate KM. At implants receiving SPAL technique, however, interproximal RBL was found apical to its ideal position.

Simplified procedures to treat periodontal intraosseous defects in esthetic areas.

Successful treatment of deep intraosseous defects in esthetic areas implies clinical improvement of the lesion consistent with long-term tooth survival as well as the preservation (or improvement) of esthetics. It is hoped that such treatment end points may be reached through procedures (which we have termed as 'simplified') that, on the one hand can be easily and successfully applied by the majority of clinicians, and, on the other hand, are well tolerated by patients in terms of postsurgical pain and discomfort, adverse events and cost. In this review, we describe the technical aspects of the simplified procedures currently available (i.e. nonsurgical therapy and the single flap approach and its variants). Also, we analyze the effect of such procedures on clinical parameters and patient-centered outcomes. While nonsurgical therapy seems to be appropriate per se in lesions with a probing depth of < 7 mm and a limited intraosseous component, severe intraosseous defects can be successfully treated using simplified surgical procedures. Overall, data support the effectiveness of simplified surgical procedures and indicate that they result in minimal esthetic impairment (i.e. post-treatment recession) and a more tolerable postoperative course when compared with conventional surgical (double flap) approaches. In particular, the single flap approach was shown to be at least as effective as traditional papilla-preservation techniques when evaluated either as a stand-alone protocol or in combination with regenerative devices. Bioactive agents have shown the most appropriate regenerative technology when used in association with simplified surgical procedures.

Clinical efficacy of a chlorhexidine-based mouthrinse containing hyaluronic acid and an antidiscoloration system in patients undergoing flap surgery: A triple-blind, parallel-arm, randomized controlled trial.

OBJECTIVES: To evaluate the postsurgery gingival healing as well as plaque, gingival inflammation and staining levels following the use of a 0.2% chlorhexidine (CHX) solution with or without antidiscoloration system (ADS) and 0.2% hyaluronic acid (HA). METHODS: Patients undergoing flap surgery at sites with an intact or reduced but healthy periodontium participated in a parallel-arm RCT. After surgery, patients used the assigned mouthrinse (CHX + HA + ADS or CHX) for 21 days. At days 7 and 21, the healing process was evaluated at experimental teeth using a composite index, namely the Gingival Healing Index (GHI). GHI score was obtained as the sum of the scores related to the severity of wound dehiscence (score 1-3) and the profile of the buccal and oral aspects of the papilla (score 1-3). Therefore, GHI ranged from 2 (worst quality of healing) to 6 (optimal quality of healing). Plaque Index (PlI), Gingival Index (GI), angulated bleeding score (AngBS), and tooth and tongue staining were also assessed. RESULTS: In both groups, GHI assumed values of 5 or 6 at both days 7 and 21 in ≥50% of patients, and low median values of PlI, GI, AngBS and staining were observed during the 21-day period. Except for a significantly lower GI in CHX group at day 7, no other significant intergroup differences were found. CONCLUSIONS: Postsurgery plaque control based on either CHX or CHX + HA + ADS mouthrinses results in optimal plaque control and quality of early gingival healing along with limited tooth and tongue staining.

Single versus double flap approach in periodontal regenerative treatment.

AIM: to compare the outcomes of a regenerative strategy based on recombinant human platelet-derived growth factor-BB (rhPDGF-BB, 0.3 mg/ml) and ß-tricalcium phosphate (ß-TCP) in the treatment of intraosseous defects accessed with the Single Flap Approach (SFA) versus Double Flap Approach based on papilla preservation techniques (DFA). MATERIALS AND METHODS: Fifteen and 13 defects, randomly assigned to SFA or DFA, respectively, were grafted with rhPDGF-BB + ß-TCP. Probing parameters were assessed before and 6 months after surgery. Pain (VAS(pain)) was self-reported using a visual analogue scale. RESULTS: Twelve SFA sites and DFA 6 sites showed complete flap closure at 2 weeks post-surgery. No significant differences in 6-month changes in probing parameters and radiographic defect fill were found between groups. Significantly lower VAS(pain) was observed in SFA group compared to DFA group at day +1, +2 and +6. A significantly greater number of analgesics were consumed in the DFA group compared to the SFA group at day +1. CONCLUSIONS: When combined with rhPDGF-BB and ß-TCP, the SFA may result in similar clinical outcomes, better quality of early wound healing, and lower pain and consumption of analgesics during the first postoperative days compared to the DFA.

Functional profile of oral plaque microbiome: Further insight into the bidirectional relationship between type 2 diabetes and periodontitis.

Increasing evidence support the association between the oral microbiome and human systemic diseases. This association may be attributed to the ability of many oral microbes to influence the inflammatory microenvironment. Herein, we focused our attention on the bidirectional relationship between periodontitis and type 2 diabetes using high-resolution whole metagenomic shotgun analysis to explore the composition and functional profile of the subgingival microbiome in diabetics and non-diabetics subjects with different periodontal conditions. In the present study, the abundance of metabolic pathways encoded by oral microbes was reconstructed from the metagenome, and we identified a set of dysregulated metabolic pathways significantly enriched in the periodontitis and/or diabetic patients. These pathways were mainly involved in branched and aromatic amino acids metabolism, fatty acid biosynthesis and adipocytokine signaling pathways, ferroptosis and iron homeostasis, nucleotide metabolism, and finally in the peptidoglycan and lipopolysaccharides synthesis. Overall, the results of the present study provide evidence in favor of the hypothesis that during the primary inflammatory challenge, regardless of whether it is induced by periodontitis or diabetes, endotoxemia and/or the release of inflammatory cytokines cause a change in precursor and/or in circulating innate immune cells. Dysbiosis and inflammation, also via oral-gut microbiome axis or adipose tissue, reduce the efficacy of the host immune response, while fueling inflammation and can induce that metabolic/epigenetic reprogramming of chromatin accessibility of genes related to the immune response. Moreover, the presence of an enhanced ferroptosis and an imbalance in purine/pyrimidine metabolism provides new insights into the role of ferroptotic death in this comorbidity.

A nurse-run walk-in clinic: cost-effective alternative to non-urgent emergency department use by the uninsured.

Non-urgent healthcare problems are responsible for more than 9 million visits to the emergency department (ED) in US hospitals each year, largely due to patients' lack of access to a primary care physician. To avoid costly and unnecessary ED usage for non-urgent health problems, a walk-in clinic run by nurses (CHEER Clinic) was developed as an extension of the services provided by an existing free clinic in a low-income neighborhood of Providence, RI, with the goal of providing uninsured patients with a convenient, no-cost means of accessing healthcare. An evaluation and cost-effectiveness analysis of the clinic's first 5 months of operation were performed. During this pilot period, 256 patients were seen. When incorporating the quality-adjusted-life-year value of preventive services rendered, an estimated $1.28 million in future healthcare costs was avoided. Dividing these cost-savings by the clinic's operational cost yielded a mean return on investment of $34 per $1 invested. Adding nurse-run walk-in hours at a free clinic significantly expanded access to healthcare for uninsured patients and was cost-effective for both the clinic and the patient. Ultimately, replication of this model in community clinics serving the uninsured could reduce ED burden by treating a substantial number of non-urgent medical concerns at a lower cost than would be incurred for treatment of the same problems in EDs.

Early postoperative healing following buccal single flap approach to access intraosseous periodontal defects.

AIM: This study aims to evaluate the early postoperative healing of papillary incision wounds and its association with (1) patient/site-related factors and technical (surgical) aspects as well as with (2) 6-month clinical outcomes following buccal single flap approach (SFA) in the treatment of intraosseous periodontal defects. METHODS: Forty-three intraosseous defects in 35 patients were accessed with a buccal SFA alone or in combination with a reconstructive technology (graft, enamel matrix derivative (EMD), graft + EMD, or graft + membrane). Postoperative healing was evaluated at 2 weeks using the Early Wound-Healing Index (EHI). RESULTS: EHI ranged from score 1 (i.e., complete flap closure and optimal healing) to score 4 (i.e., loss of primary closure and partial tissue necrosis). SFA resulted in a complete wound closure at 2 weeks in the great majority of sites. A significantly more frequent presence of interdental contact point and interdental soft tissue crater, and narrower base of the interdental papilla were observed at sites with either EHI > 1 or EHI = 4 compared to sites with EHI = 1. No association between EHI and the 6-month clinical outcomes was observed. CONCLUSIONS: At 2 weeks, buccal SFA may result in highly predictable complete flap closure. CLINICAL RELEVANCE: Site-specific characteristics may influence the early postoperative healing of the papillary incision following SFA procedure. Two-week soft tissue healing, however, was not associated with the 6-month clinical outcomes.

Biologically-oriented Alveolar Ridge Preservation.

BACKGROUND: A recent systematic review failed to identify one approach for alveolar ridge preservation with superior outcomes. The present case series aimed to evaluate the dimensional changes of sites undergoing Biologically-oriented Alveolar Ridge Preservation (BARP). METHODS: The sockets were filled with a collagen sponge up to 4-5 mm from the most coronal extensions of the crest. Xenograft particles were placed to fill the coronal part. In cases with a compromised buccal/lingual bone, an additional collagen sponge was interposed between the residual cortical bone plate and the mucoperiosteal flap. A collagen sponge was placed to cover the graft. RESULTS: The study population consisted in 10 extraction sites. Mean change in bone width and vertical ridge position as observed from BARP to re-entry for implant placement were 1.3 mm (14.4%) and 0.6 mm, respectively. The mean distance between buccal and lingual flap healing by secondary intention shifted from 4.9 mm immediately after BARP to 1.8 mm at 2 weeks. No marked differences in the dimensional changes of alveolar ridge were observed between sites with intact or deficient buccal bone plate. All implants were successfully loaded at 2-3 months after placement. In one case, bone augmentation was required. CONCLUSIONS: The stratification of materials proposed in BARP-technique and the additional use of a resorbable device to stabilize graft particles at the buccal aspect provided the conditions for maintaining the ridge dimensions following tooth extraction comparable to the other technique of ARP, restricting the use of graft material to the most coronal portion of the socket.