The effect of systemic flurbiprofen on bone supporting dental implants

Post-operative pain management in dental implant surgery: a systematic review and meta-analysis of randomized clinical trials

PURPOSE

To evaluate the clinical efficacy of various analgesic medications in mitigating orofacial pain following dental implant surgery.

MATERIALS AND METHODS

A systematic search was conducted to identify randomized controlled clinical trials (RCTs). The primary outcomes examined were post-operative pain (POP) and consumption of rescue analgesics following implant placement; secondary outcomes included adverse effects, post-operative inflammation, infection, swelling, bleeding, patient satisfaction, and quality of life. Random effects meta-analysis was conducted for risk ratios of dichotomous data.

RESULTS

Nine RCTs fulfilled the eligibility criteria. Individual studies and meta-analysis of two studies indicated that nonsteroidal anti-inflammatory drugs (NSAIDs) significantly reduced POP and consumption of rescue analgesics after dental implant placement compared to placebo. Transdermal administration of NSAIDs may be superior to the oral route as it was similarly effective for POP control and resulted in fewer side effects. Glucocorticoids administered as primary analgesics or NSAID adjuvants resulted in comparable pain sensation compared to NSAIDs alone. Caffeine-containing analgesics were reported as acceptable and effective for the treatment of POP and swelling when compared to codeine adjuvants. With regard to analgesic dosing schedules, pain modulation may be most critical during the first 72 h following dental implant placement. Risk of bias assessment indicated an overall low risk of bias across the included trials.

CONCLUSION

Within the limitations of this review, POP following implant surgery may be effectively treated with the short-term use of analgesic medications. However, given the heterogeneity in the available RCTs, there is insufficient evidence to recommend an analgesic regimen following dental implant surgery.

CLINICAL RELEVANCE

Short-term use of analgesic medications may be sufficient for post-operative pain management in dental implant surgery. Ultimately, the clinician's analgesic prescription should be directed by a patient's medical history, in order to increase the success of pain management in a short period of time and decrease potential adverse effects.

TRIAL REGISTRATION

CRD42018099324.

Osseointegration Pharmacology: A Systematic Mapping Using Artificial Intelligence

Clinical performance of osseointegrated implants could be compromised by the medications taken by patients. The effect of a specific medication on osseointegration can be easily investigated using traditional systematic reviews. However, assessment of all known medications requires the use of evidence mapping methods. These methods allow assessment of complex questions, but they are very resource intensive when done manually. The objective of this study was to develop a machine learning algorithm to automatically map the literature assessing the effect of medications on osseointegration. Datasets of articles classified manually were used to train a machine-learning algorithm based on Support Vector Machines. The algorithm was then validated and used to screen 599,604 articles identified with an extremely sensitive search strategy. The algorithm included 281 relevant articles that described the effect of 31 different drugs on osseointegration. This approach achieved an accuracy of 95%, and compared to manual screening, it reduced the workload by 93%. The systematic mapping revealed that the treatment outcomes of osseointegrated medical devices could be influenced by drugs affecting homeostasis, inflammation, cell proliferation and bone remodeling. The effect of all known medications on the performance of osseointegrated medical devices can be assessed using evidence mappings executed with highly accurate machine learning algorithms.

Medication-related dental implant failure: Systematic review and meta-analysis

OBJECTIVES

The aim of this systematic review was to investigate the association between the intake of systemic medications that may affect bone metabolism and their subsequent impact on implant failures.

MATERIAL AND METHODS

Electronic and manual literature searches were conducted. Implant failure (IF) was the primary outcome, while biological/mechanical and the causes/timing associated with IF were set as secondary outcomes. Meta-analyses for the binary outcome IF and odds ratio were performed to investigate the association with medications.

RESULTS

A final selection of 17 articles was screened for qualitative assessment. As such, five studies focused on evaluating the association of implant failure and non-steroidal anti-inflammatory drugs (NSAIDs), two on selective serotonin reuptake inhibitors (SSRIs), two on proton pump inhibitors (PPIs), seven on bisphosphonates (BPs), and one on anti-hypertensives (AHTNs). For PPIs, the fixed effect model estimated a difference of IF rates of 4.3%, indicating significantly higher IF rates in the test compared to the control group (p < 0.5). Likewise, for SSRIs, the IF was shown to be significantly higher in the individuals taking SSRIs (p < 0.5) as estimated a difference of 7.5%. No subset meta-analysis could be conducted for AHTNs medications as only one study fulfilled the inclusion criteria, which revealed an increased survival rate of AHTN medication. None of the other medications yielded significance.

CONCLUSIONS

The present systematic review showed an association of PPIs and SSRIs with an increased implant failure rate. Hence, clinicians considering implant therapy should be aware of possible medication-related implant failures.

Systemic drugs that influence titanium implant osseointegration

Titanium implants are widely used on an increasing number of patients in orthopedic and dental medicine. Despite the good survival rates of these implants, failures that lead to important socio-economic consequences still exist. Recently, research aimed at improving implant fixation, a process called osseointegration, has focused on a new, innovative field: systemic delivery of drugs. Following implant fixation, patients receive systemic drugs that could either impair or enhance osseointegration; these drugs include anabolic and anti-catabolic bone-acting agents in addition to new treatments. Anabolic bone-acting agents include parathyroid hormone (PTH) peptides, simvastatin, prostaglandin EP4 receptor antagonist, vitamin D and strontium ranelate; anti-catabolic bone-acting agents include compounds like calcitonin, biphosphonates, RANK/RANKL/OPG system and selective estrogen receptor modulators (SERM). Examples of the new therapies include DKK1- and anti-sclerostin antibodies. All classes of treatments have proven to possess positive impacts such as an increase in bone mineral density and on osseointegration. In order to prevent complications from occurring after surgery, some post-operative systemic drugs are administered; these can show an impairment in the osseointegration process. These include nonsteroidal anti-inflammatory drugs, proton pump inhibitors and selective serotonin reuptake inhibitors. The effects of aspirin, acetaminophen, opioids, adjuvants, anticoagulants and antibiotics in implant fixations are not fully understood, but studies are being carried out to investigate potential ramifications. It is currently accepted that systemic pharmacological agents can either enhance or impair implant osseointegration; therefore, proper drug selection is essential. This review aims to discuss the varying effects of three different classes of treatments on improving this process.

Effects of NSAIDs and hydroxyapatite coating on osseointegration

PURPOSE

The aim of our study is to investigate the bone ongrowth of two different alternative surfaces and the effect of nonsteroidal anti-inflammatory drugs (NSAIDs) on osseointegration.

METHODS

Hips of 40 New Zealand white rabbits were operated bilaterally. Hydroxyapatite (HA)-coated titanium rods were implanted into the right femur, and grit-blasted titanium rods were implanted into the left femur. They were divided into three groups. At the end of 8 weeks, both femora of the rabbits were removed and investigated biomechanically and histologically.

RESULTS

HA-coated implants had a significantly better failure load and "percentage of bone-implant contact" than grit-blasted implants. There was no significant difference between the medication groups as a result of the biomechanical and histologic investigations.

CONCLUSIONS

Our results indicate that NSAIDs did not have any negative effect on the osseointegration. HA-coated implants may provide more tensile strength and greater bone-implant contact rate in comparison with grit-blasted implants.

Pre- and post-operative management of dental implant placement. Part 1: management of post-operative pain

Although dental implant placements have high success rates and a low incidence of morbidity, post-operative pain and complications with the healing process have been reported. There is little guidance available regarding optimal pre- and post-operative management of dental implant placement. This first paper discusses the mechanisms of pain associated with dental implant placement and offers guidance to clinicians on optimal pre- and post-operative pain management regimes. The second paper aims to discuss pre- and post-operative means of reducing the risk of early healing complications.

Effects of Nonsteroidal Anti-inflammatory Drugs on Osseointegration: A Review

The purpose of this study was to review the effects of nonsteroidal anti-inflammatory drugs on osseointegration and determine whether they cause failures in dental implants and whether patients who use them chronically can receive dental implants safely. A bibliographic electronic search was performed using the Cochrane Library, PubMed, and Medline databases, selecting articles published between January 1982 and December 2012. The search included the following keywords, either alone or combined: “nonsteroidal anti-inflammatory drugs,” “dental implants,” “bone healing,” and “osteoprogenitor cells.” The inclusion criteria were the following: randomized, double-blind, placebo-controlled clinical studies, in vivo animal model studies of osseointegration, and in vitro studies of the effects of these agents on osteoprogenitor cells. The literature search revealed 360 references. A total of 31 articles met the inclusion criteria, including 2 clinical trials, 20 animal studies, and 9 osteoprogenitor cell studies. The clinical trials revealed that cyclooxygenase-1 (COX-1) inhibitors did not impair osseointegration. The animal studies showed that any drug that is capable of inhibiting COX-2 may impair the osseointegration process. The in vitro studies showed that COX-2 inhibitors are the most potent depressors of osseointegration at the cellular level. Caution must be taken when selecting COX-2 nonsteroidal anti-inflammatory drugs during the postoperative period.

Perioperative use of non-steroidal anti-inflammatory drugs might impair dental implant osseointegration

OBJECTIVE

To appraise whether adverse biological events following oral implant placement may be associated with perioperative use of non-steroidal anti-inflammatory drugs (NSAIDs).

METHODS

All patients treated in a university faculty postgraduate dental clinic between 1979 and 2012 that had experienced a failing and surgically removed dental implant (292 implants in 168 patients) were contacted to solicit additional information about their present dental and medical status and frequency of current and past use of NSAIDs. Potential associations between perioperative NSAIDs use and the occurrence of adverse biological events were explored by the use of 2 × 2 tables and two-tailed Fisher's exact tests.

RESULTS

One hundred and four patients with initially 468 implants had experienced 238 implant failures, of which 197 were due to failing osseointegration (42%). Sixty of the participants, initially with 273 implants, had used NSAIDs perioperatively and experienced 44% implant failures, versus 38% in the non-NSAID cohort. The NSAID cohort experienced 3.2 times more cases of radiographic bone loss greater than 30% of the vertical height of their remaining implants and 1.9 times more cases of cluster failures, defined as failure of 50% or more of the implant(s) placed.

CONCLUSIONS

Notwithstanding that a retrospective study design is open to potential bias, the current data indicate that dental implant osseointegration may be affected negatively by an inhibitory effect of NSAIDs on bone healing in vulnerable patients. Future and better clinical studies than the current should be designed to appraise more precisely the potential effects of NSAIDs on implant osseointegration in study populations that are not limited by stringent medical inclusion and exclusion criteria.

Investigation of the effect of ibuprofen on the healing of osseointegrated oral implants

OBJECTIVE

To investigate the effect of a 1-week postoperative course of 600 mg of ibuprofen taken four times a day on marginal bone level around oral implants.

MATERIALS AND METHODS

Twenty-eight patients were allocated to the ibuprofen group (14 patients) or no-ibuprofen group (14 patients). Overall, 57 implants were inserted, 31 implants in the ibuprofen group and 26 in the no-ibuprofen group. The primary outcome measure was the change in marginal bone level around oral implants from baseline (2 weeks postplacement) to the 3- and 6-month radiographic examinations. The paralleling technique and a film holder coupled to a beam-aiming device were used to take the periapical radiographs. Measurement of changes in bone level was made using a viewing box and ×8 magnifier.

RESULTS

Three subjects were withdrawn from the therapy early as they did not complete the dose of ibuprofen (e.g. because of self-reported stomach upset). The mean marginal mesial bone loss from the baseline was 0.37 mm at the 3-month and 0.27 mm at the 6-month follow up for the ibuprofen group, while the corresponding values for the no-ibuprofen group were 0.15 mm and 0.08 mm. The mean marginal distal bone loss from the baseline was 0.42 mm at the 3-month and 0.2 mm at the 6-month follow up for the ibuprofen group, while the corresponding values for the no-ibuprofen group were 0.08 mm and 0.15 mm. There were no significant differences between the ibuprofen and no-ibuprofen groups when comparing the bone changes.

CONCLUSION

Administration of a short course of systemic ibuprofen for postoperative pain management following implant insertion may not have a significant effect on the marginal bone loss around oral implants in the early healing phase.

Interventions for replacing missing teeth: maintaining and recovering soft tissue health around dental implants

BACKGROUND

It is important to institute an effective supportive therapy to maintain or recover soft tissue health around dental implants. Different maintenance regimens have been suggested, however it is unclear which are the most effective.

OBJECTIVES

To assess the effects of different interventions for 1) maintaining and 2) recovering soft tissue health around osseointegrated dental implants.

SEARCH STRATEGY

We searched the Cochrane Oral Health Group's Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE. Handsearching included several dental journals. We checked the bibliographies of the identified randomised controlled trials (RCTs) and relevant review articles for studies outside the handsearched journals. We wrote to authors of all identified RCTs, to more than 55 oral implant manufacturers and to an Internet discussion group to find unpublished or ongoing RCTs. No language restrictions were applied. The last electronic search was conducted on 2 June 2010.

SELECTION CRITERIA

All randomised controlled trials comparing agents or interventions for maintaining or recovering healthy tissues around dental implants.

DATA COLLECTION AND ANALYSIS

Screening of eligible studies, assessment of the methodological quality of the trials and data extraction were conducted in duplicate and independently by two review authors. Results were expressed as random-effects models using standardised mean differences for continuous data and risk ratios for dichotomous data with 95% confidence intervals.

MAIN RESULTS

Five trials compared interventions for maintaining soft tissue health around implants and a further six trials compared interventions to recover soft tissue health where there was evidence of peri-implant mucositis. No statistically significant differences were found between the effectiveness of powered versus manual toothbrushes for either maintaining or recovering soft tissue health. There was no statistically significant difference found between different types of self administered antimicrobials for maintaining soft tissue health (hyaluronic acid gel compared to chlorhexidine gel, amine fluoride/stannous fluoride mouthwash compared to chlorhexidine mouthwash) and triclosan dentifrice compared to sodium fluoride dentifrice showed no statistically significant difference in recovering soft tissue health. However chlorhexidine irrigation was more effective in reducing plaque and marginal bleeding scores compared to chlorhexidine mouthwash and Listerine mouthwash was found to be statistically significantly better than placebo with regard to reducing mean plaque scores and marginal bleeding scores. When interventions administered by dental professional were compared there was no statistically significant difference found between chlorhexidine and physiologic solutions as irrigants at second stage surgery to maintain health of soft tissues. In patients with peri-implant mucositis two trials evaluated interventions performed by dental professionals. There was no statistically significant difference between mechanical debridement followed by either minocycline or chlorhexidine gel, or between debridement with a titanium curette compared to an ultrasonic debridement tool.

AUTHORS' CONCLUSIONS

There was only low quality evidence for which are the most effective interventions for maintaining or recovering health of peri-implant soft tissues. The included RCTs had short follow-up periods and few subjects and although overall the risk of bias of the studies was either low or unclear, only single trials were available for each outcome. There was no reliable evidence as to which regimens are most effective for long term maintenance. This should not be interpreted as meaning that current maintenance regimens are ineffective. There was weak evidence that antibacterial mouthrinses are effective in reducing plaque and marginal bleeding around implants. More RCTs should be conducted in this area. In particular, there is a definite need for trials powered to find possible differences, using primary outcome measures and with much longer follow up. Such trials should be reported according to the CONSORT guidelines (www.consort-statement.org/).

Influence of nonsteroidal anti-inflammatory drugs on osseointegration

This paper reviews contemporary literature concerning the possible influence of nonsteroidal anti-inflammatory drugs (NSAIDs) on osseointegration. In vitro studies concerning the effect of NSAIDs on growth factors and bone-generating cells are the primary source of data pertaining to this issue because relatively few in vivo studies have been conducted. It is concluded that prescribing NSAIDs during the early postoperative period is likely not without negative effect, although any negative influence appears to be temporary and does not affect the final outcome of osseointegration.

Interventions for replacing missing teeth: maintaining and recovering soft tissue health around dental implants

BACKGROUND

It is important to institute an effective supportive therapy to maintain or recover soft tissue health around dental implants. Different maintenance regimens have been suggested, however it is unclear which are the most effective.

OBJECTIVES

To test the null hypotheses of no difference between different interventions (1) for maintaining healthy peri-implant soft tissues, and (2) for recovering soft tissue health, against the alternative hypothesis of a difference.

SEARCH STRATEGY

We searched the Cochrane Oral Health Group's Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE. Handsearching included several dental journals. We checked the bibliographies of the identified randomised controlled trials (RCTs) and relevant review articles for studies outside the handsearched journals. We wrote to authors of all identified RCTs, to more than 55 oral implant manufacturers and to an internet discussion group to find unpublished or ongoing RCTs. No language restrictions were applied. The last electronic search was conducted on 13 June 2007.

SELECTION CRITERIA

All randomised controlled trials comparing agents or interventions for maintaining or recovering healthy tissues around dental implants.

DATA COLLECTION AND ANALYSIS

Screening of eligible studies, assessment of the methodological quality of the trials and data extraction were conducted in duplicate and independently by two review authors. Results were expressed as random-effects models using standardised mean differences for continuous data and risk ratios for dichotomous data with 95% confidence intervals.

MAIN RESULTS

Eighteen RCTs were identified. Nine of these trials, which reported results from a total of 238 patients, were included. Follow ups ranged between 6 weeks and 1 year. No meta-analysis could be made since every RCT tested different interventions. Listerine mouthwash showed a reduction of 54% in plaque and 34% in marginal bleeding compared with a placebo. Two trials evaluated the efficacy of powered and sonic toothbrushes compared to manual toothbrushing and showed no statistically significant differences, though more patients liked the sonic brush. No statistical differences were found between brushing with a hyaluronic or a chlorhexidine gel, between cleaning with an etching gel or manually, between injecting a chlorhexidine or a physiologic solution inside the implant's inner part and between submucosal minocycline and a chlorhexidine gel. When an amine fluoride/stannous fluoride (AmF/SnF(2)) mouthrinse was compared with a chlorhexidine one, no statistically significant differences were found for implant failures and staining index while patients preferred and had less taste change with the AmF/SnF(2) mouthrinse. Self administered subgingival chlorhexidine irrigation resulted in statistically significantly lower plaque and marginal bleeding than a chlorhexidine mouthwash, however the mouthwash was given at a suboptimal dosage.

AUTHORS' CONCLUSIONS

There was only little reliable evidence for which are the most effective interventions for maintaining or recovering health of peri-implant soft tissues. The included RCTs had short follow-up periods and few subjects. There was not any reliable evidence for the most effective regimens for long term maintenance. This should not be interpreted as current maintenance regimens are ineffective. There was weak evidence that Listerine mouthwash, used twice a day for 30 seconds, as an adjunct to routine oral hygiene, is effective in reducing plaque and marginal bleeding around implants. More RCTs should be conducted in this area. In particular, there is a definite need for trials powered to find possible differences, using primary outcome measures and with much longer follow up. Such trials should be reported according to the CONSORT guidelines (http://www.consort-statement.org/).

Randomized clinical trials in implant therapy: relationships among methodological, statistical, clinical, paratextual features and number of citations

OBJECTIVES

The aim of the present study was to investigate the relationships among reported methodological, statistical, clinical and paratextual variables of randomized clinical trials (RCTs) in implant therapy, and their influence on subsequent research.

MATERIALS AND METHODS

The material consisted of the RCTs in implant therapy published through the end of the year 2000. Methodological, statistical, clinical and paratextual features of the articles were assessed and recorded. The perceived clinical relevance was subjectively evaluated by an experienced clinician on anonymous abstracts. The impact on research was measured by the number of citations found in the Science Citation Index. A new statistical technique (Structural learning of Bayesian Networks) was used to assess the relationships among the considered variables.

RESULTS

Descriptive statistics revealed that the reported methodology and statistics of RCTs in implant therapy were defective. Follow-up of the studies was generally short. The perceived clinical relevance appeared to be associated with the objectives of the studies and with the number of published images in the original articles. The impact on research was related to the nationality of the involved institutions and to the number of published images.

CONCLUSIONS

RCTs in implant therapy (until 2000) show important methodological and statistical flaws and may not be appropriate for guiding clinicians in their practice. The methodological and statistical quality of the studies did not appear to affect their impact on practice and research. Bayesian Networks suggest new and unexpected relationships among the methodological, statistical, clinical and paratextual features of RCTs.

Assessment of Bias in Methodology for Randomized Controlled Trials Published on Implant Dentistry

PURPOSE

The purpose of this study was to assess randomized controlled trials (RCTs) published on implant dentistry over a 10-year period (1991 to 2000), based on the reporting of control of potential sources of bias in the design methodology.

MATERIALS AND METHODS

A MEDLINE search was conducted for RCTs using keywords dental implant and publication type randomized controlled trial. Three areas of trial methodology were assessed: (1) adequate reporting of randomization procedure, (2) blinding in assessment of outcomes, and (3) handling of subject withdrawals in data analysis. A score of 1 or 0 was assigned for each of the three potential sources of bias. Thus, the maximum quality score for an RCT is 3 and the minimum is 0.

RESULTS

Forty-three articles met criteria for classification as RCTs. Method of randomization was explicit in 51% of the RCTs, but only 12% incorporated blinding in the assessment of outcome. Ninety-eight percent accounted for all subjects at the end of the study. Looking at overall quality scores, only 2% of RCTs adequately reported on control of bias in the three areas examined, 56% were deficient in one area, and 42% were deficient in two areas.

CONCLUSION

Reporting of randomization procedures and blinding in outcomes assessment for most implant RCTs was inadequate. Subject retention and documentation of subject withdrawals were adequately reported.

A review of selected dental literature on evidence-based treatment planning for dental implants: Report of the Committee on Research in Fixed Prosthodontics of the Academy of Fixed Prosthodontics

This literature review summarizes research with the aim of providing dentists with evidence-based guidelines to apply when planning treatment with osseointegrated implants. Peer-reviewed literature published in the English language between 1969 and 2003 was reviewed using Medline and hand searches. Topics reviewed include systemic host factors such as age, gender, various medical conditions, and patient habits, local host factors involving the quantity and quality of bone and soft tissue, presence of present or past infection and occlusion, prosthetic design factors, including the number and arrangement of implants, size and coatings of implants, cantilevers and connections to natural teeth, and methods to improve outcomes of implant treatment in each category. The review demonstrated that there is no systemic factor or habit that is an absolute contraindication to the placement of osseointegrated implants in the adult patient, although cessation of smoking can improve outcome significantly. The most important local patient factor for successful treatment is the quality and quantity of bone available at the implant site. Specific design criteria are provided, including guidelines for spacing of implants, size, materials, occlusion, and fit. Limitations in the current body of knowledge are identified, and directions for future research are suggested.

Periodontal host modulation with antiproteinase, anti-inflammatory, and bone-sparing agents. A systematic review

BACKGROUND

The use of modulating agents, including inhibition of matrix metalloproteinases (MMPs) with antiproteinases, blocking production of proinflammatory cytokines and prostaglandins with anti-inflammatory drugs, and inhibiting activation of osteoclasts with bone-sparing agents, has been postulated to be of therapeutic value as an adjunctive therapy to the management of chronic periodontitis.

RATIONALE

The objective of this systematic review of the literature was to assess the adjunctive efficacy of antiproteinase, anti-inflammatory, and bone-sparing host-modulating agents in the treatment of gingivitis, aggressive periodontitis, and chronic periodontitis. FOCUSED QUESTIONS: 1. In patients with periodontal diseases, what is the effect of host-modulation agents, alone or combined with conventional therapy, compared to conventional therapy alone as assessed by clinical, radiographic, adverse, and patient-centered outcomes? 2. In patients with dental implants, what is the effect of host-modulation agents on implant success assessed by clinical, radiographic, adverse, and patient-centered outcomes?

SEARCH PROTOCOL

MEDLINE, Embase, and the Cochrane Library databases were searched without language restrictions through April 1, 2002 for studies that used tetracycline (TET)-related matrix metalloproteinase (MMP) inhibitors, or non-steroidal anti-inflammatory drugs (NSAIDs) and bisphosphonate anti-osteolytic agents. The investigation also included hand searching of journals and contacting authors and industry experts.

SELECTION CRITERIA

INCLUSION CRITERIA

Only human studies (randomized controlled clinical trials, cohort studies, case-control studies, cross-sectional studies, and case series) were selected. Studies were on subjects with gingivitis, aggressive or chronic periodontitis, or dental implants. Interventions included TET-related MMP inhibitors, NSAIDs, or bisphosphonate anti-osteolytic agents.

EXCLUSION CRITERIA

Studies that used MMP tissue inhibitors as diagnostic or prognostic indicators of periodontal disease or that evaluated short-term systemic antibodies or locally delivered levels of drugs with antiproteinase activity were excluded.

DATA COLLECTION AND ANALYSIS

The primary outcomes for assessment were changes in bone or clinical attachment levels (CAL); secondary outcomes included clinical measures of plaque, gingival inflammation, probing depth (PD), and mobility. Summary data appropriate for meta-analysis were pooled using a weighted average and analyzed using a standardized difference; the results were checked with both fixed-effects and random-effects models.

MAIN RESULTS

1. A meta-analysis done on the studies reporting changes in CAL and PD following administration of sub-antimicrobial doses of doxycycline (SDD) in conjunction with scaling and root planing (SRP) in patients with periodontitis showed a statistically significant beneficial adjunctive effect. 2. There were insufficient data to provide meta-analyses on periodontal patients treated with other host-modulating agents; descriptive tables are included. 3. NSAIDS show promise in their ability to slow periodontal disease. 4. Preliminary data on bisphosphonate agents indicate there is a potential role for these agents in periodontitis management. 5. There are a very limited number of studies on host-modulating agents and dental implants and no analyses were possible. 6. Because the treatment methodologies and clinical variables differed considerably among the studies, it is difficult to summarize the information and identify a reliable total patient population.

REVIEWERS' CONCLUSIONS

1. Large multi-center trials are needed to evaluate the role of host-modulating agents in the treatment of periodontitis. 2. NSAIDS and bisphosphonate drugs may have a potential adjunctive role in periodontal therapy. 3. The adjunctive use of SDD with SRP is statistically more effective than SRP alone in reducing PD and in achieving CAL gain.

Interventions for replacing missing teeth: maintaining health around dental implants

BACKGROUND

To maintain healthy tissues around dental implants it is important to institute an effective preventive regimen (supportive therapy). Different maintenance regimens have been suggested, however it is unclear which are the most effective.

OBJECTIVES

To test the null hypothesis of no difference between different interventions for maintaining healthy tissues around dental implants.

SEARCH STRATEGY

We searched the Cochrane Oral Health Group's Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE. Handsearching included several dental journals. We checked the bibliographies of the identified randomised controlled trials (RCTs) and relevant review articles for studies outside the handsearched journals. We wrote to authors of all identified RCTs, to more than 55 oral implant manufacturers and an internet discussion group to find unpublished or ongoing RCTs. No language restrictions were applied. The last electronic search was conducted on 2 February 2004.

SELECTION CRITERIA

All randomised controlled trials of oral implants comparing agents or interventions for maintaining or recovering healthy tissues around dental implants.

DATA COLLECTION AND ANALYSIS

We carried out a quality assessment of the included RCTs in duplicate and contacted the authors for missing information. We independently extracted the data in duplicate. We followed the Cochrane Oral Health Group's statistical guidelines.

MAIN RESULTS

Fourteen RCTs were identified. Five of these trials, which reported results from a total of 127 patients, were suitable for inclusion in the review. Two trials evaluated the efficacy of powered and sonic toothbrushes, respectively, when compared to manual toothbrushing and showed no statistically significant differences. One RCT compared Listerine versus placebo mouthwashes showing a reduction of 54% in plaque and 34% in marginal bleeding compared with the placebo. One trial compared self administered subgingival chlorhexidine irrigation versus chlorhexidine mouthwash. The group using chlorhexidine irrigation resulted in statistically significantly lower mean plaque scores and a marginal bleeding index than the group using chlorhexidine mouthwash, however the mouthwash was given at a suboptimal dosage. One study compared etching gel with mechanical debridement showing no statistical differences. Follow ups ranged between 6 weeks and 5 months. It was not possible to make any meta-analysis as each trial assessed different interventions.

REVIEWERS' CONCLUSIONS

There is only little reliable evidence for which are the most effective interventions for maintaining health around peri-implant tissues. There was no evidence that the use of powered or sonic toothbrushes was superior to manual toothbrushing. There is weak evidence that Listerine mouthwash, used twice a day for 30 seconds, as adjunct to routine oral hygiene is effective in reducing plaque formation and marginal bleeding around implants. There was no evidence that phosphoric etching gel offered any clinical advantage over mechanical debridement. These findings are based on RCTs having short follow-up periods and few subjects. There is not any reliable evidence for the most effective regimens for long term maintenance. More RCTs should be conducted in this area. In particular, there is a definite need for trials powered to find possible differences, using primary outcome measures and with much longer follow up. Such trials should be reported according the CONSORT guidelines (http://www.consort-statement.org/).

Applying evidence based dentistry to your patients

It should be evident by now that evidence based dentistry leaves much room for the application of clinical judgment to the literature. This article points out that judgment in evaluating certain factors is essential and that the practice of evidence based dentistry is not a process of blindly following the conclusions found in the literature. Clinicians can safeguard the patient and themselves against the inappropriate use of weak or irrelevant evidence in the conduct of daily practice. This skill adds confidence to decision making in clinical practice and prevents the decline in skills throughout a career.

A digital subtraction radiography investigation of upper first molar proximal bone density changes in adolescents

The aim of this in vivo study was to investigate the ability of digital subtraction radiography to monitor changes in proximal bone density, adjacent to the upper first molars, in a group of adolescents using the Digora direct digital radiographic system to acquire images. For 57 adolescents, assessments of changes in probing attachment level at the mesio- and disto-buccal surfaces of both upper first molars and proximal crestal bone density using digital subtraction radiography were made. At the conclusion of this 21-month study attachment loss was identified in 34 (17%) of the 204 sites analysed. For sites with attachment loss a mean decrease in bone density equivalent to 5.51 mm3 aluminium (Al) was found compared to 2.96 mm3 Al for those without (p < 0.001). For the 17 subjects with attachment loss a mean equivalent to 4.66 mm3 Al was lost from the crestal bone compared with 2.56 mm3 Al for the 40 subjects without attachment loss (p < 0.01). The correlation between attachment loss and bone density changes was poor for both sites (r = 0.13), p = 0.067) and mean scores for subjects (r = 0.24, p = 0.069). A visual qualitative assessment of bone density change found that 70.6% of sites with attachment loss compared to 62.4% of those without had a decrease in crestal bone density. This study suggests that it is possible to monitor bone density changes in adolescents, with a developing dentition, using digital subtraction radiography. Further, it is suggested that conventional probing assessments of attachment level may underestimate the level of destructive periodontal disease in this age group.

Evaluation of a dental subtraction radiography system

The aim of this in vitro study was to evaluate the ability of a dental subtraction radiography system to quantitatively detect differences in density between radiographic image pairs. Four periapical radiographs were taken of the upper first permanent molars on five human skulls using the Digora radiographic imaging system. The 4 images were a "baseline" image and 3 containing test objects consisting of either 0.5, 1 or 2 mm thick aluminium cylinders, 2.5 mm in diameter. Semi-automated image processing software was used to "warp" the 3 images with test objects into the same geometric/density registration as the corresponding baseline image using a process called patch minimization. "Difference" images were than produced and their contrast stretched. For regions of interest, with and without test objects present, the difference in density between the baseline and "test object" images was calculated using a reference aluminium step wedge. The test objects were clearly visible in all the "difference" images. The mean difference between the actual and estimated volume of the test object was 0.31 (95% CI [-0.55, 1.17]) mm3 Al. There was a strong association (r = 0.83) between the actual and estimated aluminium volumes. It is concluded that this system provides adequate precision for clinical evaluation.

Advanced imaging methods

Recent developments in imaging sciences have enabled dental researchers to visualize structural and biophysical changes effectively. New approaches for intra-oral radiography allow investigators to conduct densitometric assessments of dento-alveolar structures. Longitudinal changes in alveolar bone can be studied by computer-assisted image analysis programs. These techniques have been applied to dimensional analysis of the alveolar crest, detection of gain or loss of alveolar bone density, peri-implant bone healing, and caries detection. Dental applications of computed tomography (CT) include the detailed radiologic anatomy of alveolar processes, orofacial soft tissues and air spaces, and developmental defects. Image analysis software permits bone mass mineralization to be quantified by means of CT data. CT has also been used to study salivary gland disease, injuries of the facial skeleton, and dental implant treatment planning. Magnetic resonance imaging (MRI) has been used extensively in retrospective and prospective studies of internal derangements of the temporomandibular joint. Assessments based on MRI imaging of the salivary glands, paranasal sinuses, and cerebrovascular disease have also been reported. Magnetic resonance spectroscopy (MRS) has been applied to the study of skeletal muscle, tumors, and to monitor the healing of grafts. Nuclear imaging provides a sensitive technique for early detection of physiological changes in soft tissue and bone. It has been used in studies of periodontitis, osteomyelitis, oral and maxillofacial tumors, stress fractures, bone healing, temporomandibular joint, and blood flow. This article includes brief descriptions of the technical principles of each imaging modality, reviews their previous uses in oral biology research, and discusses potential future applications in research protocols.