Peri-implantitis: lack of high quality studies for surgical regenerative treatment

implant astra

Implant treatment has a well-established body of evidence supporting its long-term success and efficacy. Following in the shadow of this success however we now have the problem of peri-implantitis, characterised by inflammation and degeneration of the hard and soft tissues surrounding the implant and eventually leading to its loss from the jaw bone. Various techniques have been advocated to treat this infection taking its origins from periodontal treatment such as non-surgical, surgical and regenerative procedures.

The purpose this study was to systematically review the literature on the surgical regenerative treatment of the peri-implantitis and to determine an effective therapeutic predictable option for its clinical management.

Methods

The review followed the PRISMA statement  (Moher et al. 2009) the protocol was also registered on the International Prospective Register of Systematic Reviews (PROSPERO) database. Searches were carried by two independent researchers using Ovid MEDLINE, PubMed, Embase, and Dentistry and Oral Sciences Source. Databases were searched from January 2006 to March 2016 and restricted to English, manual searches were also carried out in the relevant major journals. Inclusion criteria were: Human prospective and retrospective observational studies involving at least one surgical regenerative treatment method for peri-implantitis. Minimum sample size was 10 implants with no less than 12 months follow-up. Excluded studies included animal and in vitro studies, patients with uncontrolled systemic disease that put the implant at risk and ceramic or coated implants. Quality appraisal was carried out by two independent reviewers using the Cochrane Collaboration tool for assessing risk of bias in randomised trials (Higgins JPT et al. 2011)

Results

  • From 883 records only 18 fulfilled the inclusion criteria. This included 8 prospective clinical studies, seven case series and three randomised clinical trials (RCT’s). A total of 528 patients with 713 implants were treated.
  • 2 studies were at low risk of bias, 1 moderate, and 3 high. The remainder were classified as unclear.
Total mean radiological bone level change +2.97 mm (95% CI 1.58 to 2.35)
·       Mean radiological bone level + membrane +1.86 mm (95% CI 1.36 to 2.36)
·       Mean radiological bone level – membrane +2.12 mm (95% CI 1.46 to 2.78)
·       Mean radiological bone level submerged +2.17 mm (95% CI 1.87 to 2.47)
·       Mean radiological bone level non-submerged +1.91 mm (95% CI 1.44 to 2.39)
Total mean probing depth change -2.78 mm (95% CI 2.31 to 3.25)
·       Mean probing depth change + membrane -2.88 mm (95% CI 2.31 to 3.45)
·       Mean probing depth change – membrane -2.60 mm (95% CI 1.90 to 3.30)
·       Mean probing depth change submerged -2.68 mm (95% CI 1.71 to 3.64)
·       Mean probing depth change non-submerged -2.77 mm (95% CI 2.23 to 3.30)
Total mean bleeding on probing change -55% (95% CI 45.2 to 64.4)

 

Conclusions

The authors concluded: –

Within the limits of this systematic review, surgical regenerative treatment is a predictable option in managing peri-implantitis and improving clinical parameters of peri-implant tissues. There is no fundamental advantage of membrane use for bone graft coverage or submergence of the healing site on the final outcome of peri-implant defect regeneration. Due to the limited number of randomised clinical trials, at the time there is a lack of scientific evidence in the literature regarding the superiority of the regenerative versus non-regenerative surgical treatment

Comments

There are a few points to mention in relation to this well conducted review. Firstly, there is a lack of high quality studies with only 2 out of the 18 fulfilling the criteria and how this might influence the overall meta-analysis (this is commonly missed out in dental related systematic reviews, even though it is one of the PRISMA criteria the authors mention they adhere to). PRISMA has since been updated (Moher et al. 2015).   Secondly, the risk of bias tool is designed for RCT’s (3/18) and there was no mention of using one of the tools specifically designed for non-randomised observational studies (Sterne et al. 2016; Wells 2013).

Finally, the author concludes that surgical regenerative treatment is a predictable option for the treatment of peri-implantitis but fails to mention how well or poorly this performs against standard non-regenerative debridement of the lesion. The reason I mention this is that a second paper was published by members of the same team, in the same institution, in the same month that could have shed some light on clinical effectiveness (Ramanauskaite et al. 2016).

First Posted on the National Elf Service

Links

Primary paper

Daugela P, Cicciù M, Saulacic N. Surgical Regenerative Treatments for Peri-Implantitis: Meta-analysis of Recent Findings in a Systematic Literature Review. J Oral Maxillofac Res. 2016 Sep 9;7(3):e15. eCollection 2016 Jul-Sep. Review. PubMed PMID: 27833740; PubMed Central PMCID: PMC5100640.

Other references

Original review protocol on PROSPERO

Higgins JP, Altman DG, Gøtzsche PC, Jüni P, Moher D, Oxman AD, Savovic J, Schulz KF, Weeks L, Sterne JA; Cochrane Bias Methods Group; Cochrane Statistical Methods Group. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ. 2011 Oct 18;343:d5928.

Sterne JA, Hernán MA, Reeves BC, et al. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ. 2016 Oct 12;355:i4919. doi: 10.1136/bmj.i4919. PubMed PMID: 27733354; PubMed Central PMCID: PMC5062054.

Wells, G.A., 2013. Newcastle Ottawa scale Coding Manual for Case-Control Studies. The Ottawa Hospital Research Institute.

Ramanauskaite A, Daugela P, Faria de Almeida R, Saulacic N. Surgical Non-Regenerative Treatments for Peri-Implantitis: a Systematic Review. J Oral Maxillofac Res. 2016 Sep 9;7(3):e14. eCollection 2016 Jul-Sep. Review. PubMed PMID: 27833739; PubMed Central PMCID: PMC5100639.

 

 

 

Complete overdentures retained by mini implants.

Posted Dental Elf 10/03/2017

Complete DenturesWith the advances in preventative dentistry one consequence has been patients becoming edentulous later in life. Accepting and adapting to conventional complete denture can be extremely challenging both physically and psychologically. There is now good evidence to support implant supported mandibular overdentures (Feine et al., 2002) using standard implants.
The aim of this review was to evaluate the use of mini-implants (diameter <3mm) to retain complete over-dentures in terms of survival, marginal bone loss, satisfaction and quality of life (Lemos et al, 2016).

Methods

The review followed the PRISMA statement (Moher et al., 2009) and was registered with PROSPERO.  Searches were conducted in PubMed/Medline, Embase and the Cochrane Library database checking articles published up to September 2016. In addition, they conducted a hand search of high impact journals in the field of implant retained prosthodontics. The eligibility criteria were, randomised controlled trials (RCTS) or prospective studies published in English. Two reviewers independently selected studies for inclusion, abstracted data and assessed risk of bias using the Newcastle-Ottawa Scale. The primary outcome was the survival rates of the mini implants; and the secondary outcomes included marginal bone loss, satisfaction and quality of life with the mini implants when they were used for retaining overdenture prosthesis.

Results

  • 24 studies (4 RCTs, 20 prospective observational studies).
  • Risk of bias scores were 6 papers scored 9/9, 2 scored 8/9, 2 scored 7/9, 13 scored 6/9 and one paper scored 5/9
  • A total of 2492 mini implants and 386 standard implants were placed in 896 patients.
  • Mean age 65.93
  • No formal meta-analysis was carried out
  • Primary outcomes
    • Mini implant survival rate of 92.32% over 1-7 years
    • Maxillary arch implants had a higher failure rate at 31.17%
  • Secondary outcomes
    • Marginal bone loss below 1.5mm
    • Overdenture prosthesis retained by mini implants exhibited a significant increase in retention, stability chewing, speaking, comfort, aesthetics and improvements in satisfaction/quality of life.
    • Overdenture survival 90.58%

Conclusions

The authors concluded

Within the limitations of this study, the present systematic review indicates that the use of mini implants for retaining overdenture prosthesis may be considered an alternative treatment, since it presents high survival rates of mini implants, acceptable marginal bone loss, and improvements in variables related to satisfaction and quality of life of patients.

Comments

This systematic review adopted elements of the PRISMA protocol and identified a good number of prospective studies. A risk of bias analysis was undertaken with the authors scoring 10 papers as low risk of bias and 14 at a high risk of bias. Their outcome measurements were a combination of quantitative and qualitative data. Unfortunately, there was no meta-analysis undertaken and the survival rates given were missing both confidence intervals and a time frame. A quick review of the quantitative data provided by the review authors in table 2 revealed the mode for patients per study was 30 and the mode for follow-up was I year. The two comparison systematic reviews (Dantas et al, 2014; Raghoebar et al, 2014) which the authors concurred with reference high survival rates had similar extremely short follow-up periods and small sample sizes. The results from this systematic review therefore need to be interpreted with extreme caution due to problems with the external validity of the primary research and the synthesis of that data within the review.

Links

Primary Paper

Lemos CA, Verri FR, Batista VE, Júnior JF, Mello CC, Pellizzer EP. Complete overdentures retained by mini implants: A systematic review. J Dent. 2017 Feb;57:4-13. doi: 10.1016/j.jdent.2016.11.009. Review. PubMed PMID: 27888049.

Other references

Dantas Ide S, Souza MB, Morais MH, Carreiro Ada F, Barbosa GA. Success and survival rates of mandibular overdentures supported by two or four implants: a systematic review. Braz Oral Res. 2014;28:74-80. doi: 10.1590/S1806-83242013000600012. Review. PubMed PMID: 24402059.

Feine JS, Carlsson GE, Awad MA, Chehade A, Duncan WJ, Gizani S, Head T, Lund JP, MacEntee M, Mericske-Stern R, Mojon P, Morais J, Naert I, Payne AG, Penrod J,Stoker GT, Tawse-Smith A, Taylor TD, Thomason JM, Thomson WM, Wismeijer D. The McGill consensus statement on overdentures. Mandibular two-implant overdentures as first choice standard of care for edentulous patients. Montreal, Quebec, May 24-25, 2002. Int J Oral Maxillofac Implants. 2002 Jul-Aug;17(4):601-2. Review. PubMed PMID: 12182304.

Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group.. Preferred reportingitems for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med.2009 Jul 21;6(7):e1000097. doi:10.1371/journal.pmed.1000097. PubMed PMID:19621072; PubMed Central PMCID: PMC2707599.

Raghoebar GM, Meijer HJ, Slot W, Slater JJ, Vissink A. A systematic review of implant-supported overdentures in the edentulous maxilla, compared to the mandible: how many implants? Eur J Oral Implantol. 2014 Summer;7 Suppl 2:S191-201. Review. PubMed PMID: 24977255.

Raghoebar, G. M., Meijer, H. J. A., Slot, W., Slater, J. J. R. and Vissink, A. (2014) ‘A systematic review of implant-supported overdentures in the edentulous maxilla, compared to the mandible: how many implants?’, European journal of oral implantology, 7 Suppl 2(November 2016), pp. S191-201.

 

Oral care in nursing homes

imagesOne challenge to our future healthcare system will come from the care requirement of frail patients living in residential care. Data suggests that the size of the UK population aged over 65 will rise by 60% to 16 million over the next 25 years, 5% being over 85 years old (Batchelor 2015). 80% will end up live in some form of residential home, being looked after by professional staff rather than family members (Broad et al. 2013). Two major barriers exist:

  • Residents responsive behaviour – defined as physical or verbal actions, such as grabbing, screaming, and resisting care, in response to a negatively perceived stimulus.
  • Residents lack of motivation or ability to perform their own oral hygiene.

The objective of this review is to evaluate the effectiveness of strategies that nursing home care providers can apply to either prevent/overcome residents’ responsive behaviours to oral care, or enable/motivate residents to perform their own oral care.

Methods

The review followed the PRISMA statement (the protocol was also registered on the International Prospective Register of Systematic Reviews (PROSPERO) database.
Searches were carried by two independent researchers using Medline, Embase, Evidence Based Reviews-Cochrane Central Register of Controlled Trials, CINAHL, and Web of Science. Databases were searched up to April 2016 with no language restrictions, and manual searches were also carried out in the relevant major journals.

Inclusion criteria were as follows: Qualitative observational studies and mixed-methods studies including reviews relating to strategies that formal care providers can use to motivate oral health care and overcome responsive behaviour for frail older adults in residential care. Exclusion criteria were non-empirical and qualitative research, healthy or independent residents or care provided by family, students or managers.

Study outcomes were resident’s oral health scores, self-performed oral care, responsive behaviour and level of staff assistance. 
Quality appraisal was carried out by two independent reviewers using the Quality Assessment Tool for Quantitative studies and Estabrooks Quality Assessment and Validity Tools for Cross Sectional Studies.

Results

  • From 7362 records only 7 studies fulfilled the inclusion criteria, four of which report different aspects of one research project. Therefore. 3 prospective cohort studies and 1 cross-sectional study were included.
  • Methodological quality was low/moderate for one study and weak for three studies.
  • Plaque index scores reduced by approximately 40%
  • Bleeding index scores reduced by approximately 35%
  • Denture plaque scores reduced by 23%
  • Resistance to care reduced by approximately 45%

Conclusions

The authors concluded: –

Potentially promising strategies are available that nursing home care providers can apply to prevent/overcome residents’ responsive behaviours to oral care or to enable/motivate residents to perform their own oral care. However, studies assessing these strategies have a high risk for bias. To overcome oral health problems in nursing homes, care providers will need practical strategies whose effectiveness was assessed in robust studies.

Comments

This review highlights the lack of studies relating to the important issue of oral health maintenance of frail older patients. As our population ages this problem is only going to increase in complexity. Though the results were good but the sample sizes are very small (5,7,13 and 97 patients respectively) and the duration of the study was very short (2-8 weeks).

Other longer-term observational studies not identified in this review of routine care have shown a degrading of oral hygiene irrespective of maintenance regime, and regression to 40% had unacceptable hygiene, high levels of resistance and cleaning being left largely undone with assisted tooth brushing times as low as 16 seconds (Willumsen et al. 2012; De Visschere et al. 2015; Carter et al. 2009). The reasons being increased frailty and cognitive capacity over time with the average patient staying in high dependency residential care for 16 months, compounded with high turn-over of trained care staff.   In addition the recent Cochrane review by Albrecht et al (Dental Elf – Oct 10th – 2016):-

found insufficient evidence to draw robust conclusions about the effects of oral health educational interventions for nursing home staff and residents.

Links

Original Post: Dental Elf – June 30th – 2017

Primary paper

Hoben M, Kent A, Kobagi N, Huynh KT, Clarke A, Yoon MN. Effective strategies to motivate nursing home residents in oral care and to prevent or reduce responsive behaviors to oral care: A systematic review. PLoS One. 2017 Jun 13;12(6):e0178913. doi:10.1371/journal.pone.0178913. eCollection 2017. PubMed PMID: 28609476.

Review Protocol on PROSPERO

Other references

Batchelor, P. The changing epidemiology of oral diseases in the elderly, their growing importance for care and how they can be managed. Age and Ageing, 2015 44(6), pp.1064–1070.

Broad JB, Gott M, Kim H, Boyd M, Chen H, Connolly MJ. Where do people die? An international comparison of the percentage of deaths occurring in hospital and residential aged care settings in 45 populations, using published and available statistics. Int J Public Health. 2013 Apr;58(2):257-67. doi: 10.1007/s00038-012-0394-5. Epub 2012 Aug 15. Erratum in: Int J Public Health. Int J Public Health. 2013 Apr;58(2):327. PubMed PMID: 22892713.

Carter, K.D. et al., 2009. Caring for Oral Health in Australia Residential Care. Australian Institute of  Health and Welfare, (48), pp.1–53.

De Visschere L, de Baat C, De Meyer L, van der Putten GJ, Peeters B, Söderfelt B, Vanobbergen J. The integration of oral health care into day-to-day care in nursing homes: a qualitative study. Gerodontology. 2015 Jun;32(2):115-22. doi: 10.1111/ger.12062. Epub 2013 Jun 20. PubMed PMID: 23786637.

Willumsen T, Karlsen L, Naess R, Bjørntvedt S. Are the barriers to good oral hygiene in nursing homes within the nurses or the patients? Gerodontology. 2012 Jun;29(2):e748-55. doi: 10.1111/j.1741-2358.2011.00554.x. Epub 2011 Oct 24. PubMed PMID: 22023222.