The journal of evidence-based dental practice
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J Evid Based Dent Pract · Sep 2012
CommentSurvival of short implants is improved with greater implant length, placement in the mandible compared with the maxilla, and in nonsmokers.
The authors conducted a search of MEDLINE and EMBASE databases for the period January 1980 to October 2009. This was supplemented by searching reference lists of literature obtained. There was no language restriction applied. Two authors reviewed the search yield for relevance, disagreement was resolved by consensus discussion, and the selected articles deemed relevant for full-text review were read by one reviewer. The relevant articles selected were judged against inclusion/exclusion criteria. Included studies were restricted to randomized controlled trials (RCTs) or prospective cohort studies. Only studies with partially edentulous applications of at least 5 implants shorter than 10 mm followed for more than 1 year were included. No (alumina)-zirconium implants or mini-implants for orthodontic anchorage or short implants used for cantilevered prostheses were included. A validity assessment using methodological criteria for cohort and RCTs was accomplished by 2 reviewers. ⋯ The findings from this systematic review are important in that collectively they support consideration of placement of short implants in partially edentulous patients. The estimated data showed a tendency for improved survival rate with increasing implant length, implant placement in the mandible compared with the maxilla, and for implants placed in nonsmokers.
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J Evid Based Dent Pract · Sep 2012
ReviewOral manifestations of systemic autoimmune and inflammatory diseases: diagnosis and clinical management.
Systemic autoimmune and inflammatory diseases often manifest oral lesions in their earliest stages, and early diagnosis, which may be spurred by a dental examination, is key for improved outcomes. After systemic diagnosis, oral lesions benefit from specialized care by dentists in collaboration with the medical team. This review aims to educate dental clinicians about the most relevant systemic autoimmune and inflammatory conditions with accompanying oral lesions, their implications for health, and management strategies supported by the biomedical literature and clinical experience. Ulcerative conditions including Behcet and Crohn diseases are discussed, along with rheumatic conditions including Sjögren syndrome, lupus erythematosus, and rheumatoid arthritis. ⋯ Dentists play an important role in the early detection and multidisciplinary medical management of complex autoimmune diseases. It is important to recognize prevalent medical and dental issues and special needs of patients with autoimmune conditions. The management of many inflammatory conditions is similar, and often begins with the use of topical steroids, analgesics, and antimicrobial treatments, in addition to careful attention to oral hygiene and appropriate fluoride usage. In this brief review, we aim to discuss the presentation/prevalence, diagnosis, and treatment of oral manifestations encountered in autoimmune, autoinflammatory and systemic chronic inflammatory diseases. Systemic autoimmune conditions are estimated to affect 5% to 8% of Americans.(1) Oral manifestations are encountered with high frequency, and are often the first clinical signs or symptoms of the general disease. Optimal management of complex autoimmune diseases requires a multidisciplinary medical team including dentists to care for lesions of the oral cavity. The dental practitioner may be asked to play a primary role in the diagnosis of such conditions and to participate with other health professionals working together to achieve effective clinical management. To aid in this process, we discuss in this article the current general knowledge of systemic autoimmune conditions that present with prevalent oral manifestations. The focus is on the diagnosis and management of the oral component of each disease. Importantly, whereas the etiology and pathogenesis and systemic clinical presentation may vary, presentation in the oral cavity is often similar and many conditions involve oral ulcerations. For this reason, we discuss the differential diagnosis and management of the most common oral ulcerations in a general section and subsequently address individual conditions that present with oral ulcerations. Similarly, treatment of various autoimmune/inflammatory oral conditions is often common and involves modulation or suppression of the immune response locally and/or systemically and will be therefore addressed in a common section as well as individually for each disease when unique treatment regimens are recommended. We present here our general treatment recommendations based on clinical experience and literature review; however, it is critical that good clinical judgment and specifics of an individual case should determine the appropriate dental/oral medicine intervention for a specific patient.
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J Evid Based Dent Pract · Sep 2012
CommentEssential oil mouthwash (EOMW) may be equivalent to chlorhexidine (CHX) for long-term control of gingival inflammation but CHX appears to perform better than EOMW in plaque control.
For inclusion in this systematic review, studies had to be randomized clinical trials (RCTs) or controlled trials in healthy human subjects comparing the effects of essential-oil mouthwash (EOMW) with chlorhexidine (CHX) on plaque and calculus accumulation, tooth staining, and gingival inflammation. Included studies could be either short-term (< 4 weeks' duration) or long-term (> 4 weeks' duration). Studies were required to include a specific formulation of EOMW (Listerine, Johnson and Johnson). They reportedly selected this standard formula of EOMW because it was representative of essential oil-based mouthwashes and because it has the American Dental Association seal of approval. Conversely, there were no restrictions on the concentration of CHX used in studies. The CHX concentration in studies varied from 0.1% to 0.2%. Studies could include no brushing (de novo model) or brushing in conjunction with EOMW or CHX. The authors identified 390 unique articles from electronic database searches. Twenty-five of these articles were selected for full review. Seven articles were excluded because they did not meet the inclusion criteria. Hand searching the reference list of selected manuscripts resulted in the addition of one article. The final systematic review included 19 articles, with a total of 826 subjects who completed all trials. The systematic review included short-term studies lasting less than 4 weeks and long-term studies of 4 or more weeks' duration. Six of these trials were included in the 7 separate meta-analyses performed, yielding a total of 315 participants. The age of subjects in the trials ranged from 16 to 62 years. The study by Axelsson and Lindhe was included twice in the metaanalysis of plaque index, gingival index, and stain index because CHX was used in 0.1% and 0.2% concentrations. The studies by Haffajee et al and Charles et al were each used in meta-analyses for both plaque index and gingival index. Three separate meta-analyses included assessments for plaque index, whereas 2 involved gingival index and 2 assessed tooth staining index. ⋯ The authors concluded that CHX was significantly better at reducing plaque accumulation than EOMW in short-and long-term studies. Staining and calculus accumulation were greater among CHX users compared to EOMW. CHX and EOMW were not different with respect to long-term control of gingival inflammation. They suggested that EOMW might be a reliable alternative to CHX for controlling gingival inflammation in cases where a dental professional deems that anti-inflammatory oral care is beneficial. However, they concluded that CHX remains the first choice when plaque control is the focus of therapy.
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J Evid Based Dent Pract · Sep 2012
CommentModest reduction in risk for ventilator-associated pneumonia in critically ill patients receiving mechanical ventilation following topical oral chlorhexidine.
The sample (N = 547) included patients older than 18 years (328 men and 219 women from a total population of 10,913) admitted to 3 intensive care units (ICUs) (medical, surgical/trauma, and neuroscience) at Virginia Commonwealth University Medical Center. The sample size required to detect an interaction (ie, the effect of chlorhexidine and toothbrushing in combination) was determined to be larger than that required to detect main effects (ie, chlorhexidine alone or toothbrushing alone) for a test at a given level of significance. The study was designed to detect an interactive effect resulting in a 0.755 difference in mean Clinical Pulmonary Infection Score (CPIS) at a power of 80% and a significance level of .05. An interim analysis was done and a Bonferroni adjustment was used to avoid inflation in the overall significance level related to interim analyses; for this reason, the level of significance for final analysis was .025. This was a randomized controlled clinical trial with a 2 × 2 factorial design. Patients were randomized to treatment within each ICU according to a permuted block design developed by the biostatistician before the start of the study. Staff who performed interventions (oral care) had no knowledge of patients' CPIS. Patients receiving mechanical ventilation were enrolled within 24 hours of intubation and were followed for up to 14 days. Dates of recruitment were not disclosed. ⋯ Chlorhexidine oral swabbing was effective in reducing early ventilator-associated pneumonia (VAP) (after 3 days of intervention) in patients in medical, surgical/trauma, and neuroscience ICUs who did not have evidence of lung infection at baseline. This effect was not observed after day 3. Toothbrushing did not reduce the incidence of VAP, and combining toothbrushing and chlorhexidine did not provide additional benefit over use of chlorhexidine alone.