Syncope in dental practices:a systematic review on aetiology and management

Introduction This systematic review aimed to give an overview of the current evidence sur-rounding the aetiology and management in terms of treatment and prevention of syncope in dental practices. Alongside the occurrence, the practitioner's com-petence, and the association between syncope and local anaesthetics were dis-cussed. Methods An electronic search in EMBASE, Web of Science, PubMed, Cochrane databases and a hand search were performed by 2 independent reviewers to identify stud-ies up to November 2019. Eligibility criteria were applied and relevant data was extracted. Inclusion criteria covered all types of dental treatment under local anaesthesia or conscious sedation performed by a wide range of oral health care workers in their practices. Risk of bias of the included studies was as-sessed using the methodological tools recommend by Zeng et al.1 No restric-tions were made to exclude papers from qualitive analysis based on risk of bias assessment. Results The search yielded a total of 18 studies for qualitative analysis. With the ex-ception of one prospective cohort study, all articles were considered having a high risk of bias. Meta-analysis showed that dentists encountered on average 1.2 cases of syncope per year. The male gender (RR=2.69 [1.03, 7.02]), dental fear (RR=3.55 [2.22, 5.70]), refusal of local anaesthesia in non-acute situations (OR = 12.9) and the use of premedication (RR = 4.70, [1.30, 16.90]) increased the risk for syncope. Treatment and prevention were underreported as both were solely discussed in one study. The supine recovery position with raised legs and oxygen administration (15l/min) was presented as an effective treatment. The Medical Risk-Related History (MRRH) system was proposed as prevention pro-tocol, yet this protocol was ineffective in reducing incidence rates (p = 0.27). The majority of dentists (79.2%) were able to diagnose syncope, yet most (86%) lacked the skills for appropriate treatment. Only 57,6% of dental practices were equipped with an oxygen cylinder. Conclusions Syncope is the most common emergency in dental practices. Nonetheless, the vast majority of dentists do not seem competent nor prepared to manage this emergency. Psychogenic factors seem to play an important role in provoking syncope. Placing the patient in a supine reclined position with raised legs in combination with the administration of oxygen seems effective for regaining consciousness. Although valuable in many aspects, risk assessment by medical history taking is not proven to result in fewer episodes. The strength of these conclusions is low based on GRADE guidelines.(2

Immediate implant placement with or without socket grafting : a systematic review and meta‐analysis

Objectives To assess the effect of grafting the gap (SG) between the implant surface and alveolar socket on hard and soft tissue changes following single immediate implant placement (IIP). Materials and Methods Two independent reviewers conducted an electronic literature search in Pubmed, Web of Science, Embase and Cochrane databases as well as a manual search to identify eligible clinical studies up to August 2021. Randomized controlled trials (RCTs) comparing IIP with and without SG were included for a qualitative analysis. Meta-analyses were performed when possible. Results Out of 3627 records, 15 RCTs were selected and reported on 577 patients who received 604 single immediate implants (IIP + SG: 298 implants in 292 patients; IIP: 306 implants in 285 patients) with a mean follow-up ranging from 4 to 36 months. Two RCTs showed low risk of bias. Meta-analysis revealed 0.59 mm (95% CI [0.41; 0.78], p < 0.001) or 54% less horizontal buccal bone resorption following IIP + SG when compared to IIP alone. In addition, 0.58 mm (95% CI [0.28; 0.88], p < 0.001) less apical migration of the midfacial soft tissue level was found when immediate implants were installed with SG. A trend towards less distal papillary recession was found (MD 0.60 mm, 95% CI [-0.08; 1.28], p = 0.080) when SG was performed, while mesial papillae appeared not significantly affected by SG. Vertical buccal bone changes were also not significantly affected by SG. Insufficient data were available for meta-analyses on horizontal midfacial soft tissue changes, pink esthetic score, marginal bone level changes, probing depth and bleeding on probing. Based on GRADE guidelines, a moderate recommendation for SG following IIP can be made. Conclusion SG may contribute to horizontal bone preservation and soft tissue stability at the midfacial aspect of immediate implants. Therefore, SG should be considered as an adjunct to IIP in clinical practice

Immediate implant placement with or without connective tissue graft : a systematic review and meta‐analysis

Objectives To assess the effect of connective tissue graft (CTG) in terms of vertical mid-facial soft tissue change when applied at the buccal aspect following single immediate implant placement (IIP). Materials and methods Two independent reviewers conducted an electronic literature search in PubMed, Web of Science, EMBASE and Cochrane databases as well as a manual search to identify eligible clinical studies up to January 2020. Randomized controlled trials (RCTs) and non-randomized controlled studies (NRSs) comparing IIP with CTG and without CTG over a mean follow-up of at least 12 months were included for a qualitative analysis. Meta-analyses were performed on data provided by RCTs. Results Out of 1814 records, 5 RCTs and 3 NRSs reported on 409 (IIP + CTG: 246, IIP: 163) immediately installed implants with a mean follow-up ranging from 12 to 108 months. Only 1 RCT showed low risk of bias. Meta-analysis revealed a significant difference in terms of vertical mid-facial soft tissue change between IIP + CTG and IIP pointing to 0.41 mm (95% CI [0.21; 0.61], p = 1 mm asymmetry in mid-facial vertical soft tissue level was 12 times (RR 12.10, 95% CI [2.57; 56.91], p = .002) lower following IIP + CTG. Soft tissue grafting also resulted in a trend towards less bleeding on probing (MD 17%, 95% CI [-35%; 1%], p = .06). Meta-analyses did not reveal significant differences in terms of pink aesthetic score, marginal bone level change and probing depth. Results were inconclusive for horizontal mid-facial soft tissue change and papilla height change. Based on GRADE guidelines, a moderate recommendation for the use of a CTG following IIP can be made. Conclusion CTG contributes to mid-facial soft tissue stability following IIP. Therefore, CTG should be considered when elevated risk for mid-facial recession is expected in the aesthetic zone (thin gingival biotype, <0.5 mm buccal bone thickness)

Immediate implant placement with or without immediate provisionalization : a systematic review and meta‐analysis

Aim To assess the effect of immediate provisionalization (IP) on soft tissue changes, hard tissue changes, and clinical parameters following single immediate implant placement (IIP). Materials and Methods Two independent reviewers conducted an electronic literature search in PubMed, Web of Science, Embase, and Cochrane databases as well as a manual search to identify eligible clinical studies up to September 2021. Randomized controlled trials (RCTs) comparing IIP with IP (test) and IIP without IP (control) were included for a qualitative and quantitative analysis. The primary outcome was vertical midfacial soft tissue changes. Secondary outcomes included horizontal midfacial soft tissue changes, implant survival, mesial and distal papillary changes, Pink Esthetic Score (PES) at final follow-up, marginal bone-level changes, probing depth at final follow-up, and bleeding on probing at final follow-up. Results Of the 8213 records, 7 RCTs reporting on 323 patients who received 323 single immediate implants (IIP + IP: 161 implants in 161 patients; IIP: 162 implants in 162 patients) were selected with a mean follow-up ranging from 12 to 60 months. Risk of bias assessment yielded some concerns for five RCTs and high risk for two RCTs. Meta-analysis on the cases with intact alveoli demonstrated 0.87 mm (95% confidence interval [CI] [0.57; 1.17], p < .001) less apical migration of the midfacial soft tissue level for IIP + IP when compared to IIP alone. Implant survival, papillary changes, marginal bone-level changes, probing depth, and bleeding on probing were not significantly affected by IP. Insufficient data were available for meta-analyses on horizontal midfacial soft tissue changes and PES. Conclusions IP may contribute to midfacial soft tissue stability at immediate implants. However, high-quality RCTs are needed since the strength of this conclusion is currently rated as low according to GRADE guidelines

A 5‐year cohort study on early implant placement with guided bone regeneration or alveolar ridge preservation with connective tissue graft

Purpose To assess on the one hand the 5-year outcome of early implant placement with guided bone regeneration (EIP/GBR) and on the other hand of alveolar ridge preservation with late implant placement and connective tissue graft (ARP/CTG). Materials and methods Patients who had been treated with a single implant in the anterior maxilla in 2014 were selected for reevaluation in 2019. In the EIP/GBR cohort, implants were installed 4 to 8 weeks following extraction and the buccal contour was overbuilt by means of GBR. In the ARP/CTG cohort, collagen-enriched deproteinized bovine bone mineral was applied at the time of extraction and implants were installed 5 months later. All ARP/CTG cases received a buccal CTG 3 months after implant installation to reestablish buccal convexity. Primary outcomes were the pink esthetic score (PES) (Belser et al 2009) and the mucosal scarring index (MSI) (Wessels et al 2019). Clinical and radiographical parameters were secondary outcomes. Results Eighteen patients (9 females; mean age 52) in the EIP/GBR cohort, and 20 patients (9 females; mean age 38) in the ARP/CTG cohort were evaluated. PES was 6.28 following EIP/GBR. A (nearly) perfect aesthetic outcome defined as PES >= 8 was found in 3/18 cases. Perfect root convexity / soft tissue color and texture seemed most difficult to achieve. PES was 7.80 following ARP/CTG. A (nearly) perfect aesthetic outcome was found in 11/20 cases. MSI was 2.94 following EIP/GBR with 14/18 cases showing scarring. MSI yielded 0.50 following ARP/CTG with 6/20 cases showing scarring. In both cohorts, all implants survived, and none had developed periimplantitis. However, implants in the ARP/CTG cohort demonstrated a 5.4 times higher risk for periimplant mucositis than implants in the EIP/GBR cohort at 5 years follow-up. Conclusion EIP/GBR and ARP/CTG showed acceptable long-term outcomes. The aesthetic outcome was particularly favorable following ARP/CTG, yet this should be interpreted with caution due to selection bias and because soft tissue grafting was not performed in the EIP/GBR cohort. Randomized controlled trial (RCTs) comparing EIP with ARP are required to assess the need for soft tissue grafting and to evaluate clinical, aesthetic, volumetric, and patient-reported outcomes. Only on the basis of such studies clinical recommendations can be made

A one-year prospective study on alveolar ridge preservation using collagen-enriched deproteinized bovine bone mineral and saddle connective tissue graft : a cone beam computed tomography analysis

Background Although there is ample research on alveolar ridge preservation (ARP), changes of the soft tissue profile are seldom reported. In addition, the use of a saddle connective tissue graft (S-CTG) has only been described in one study. Purpose To evaluate changes in bone and external soft tissue profile following ARP of intact and nonintact sockets using collagen-enriched deproteinized bovine bone mineral (C-DBBM) and a S-CTG (a); to assess the need for additional hard and soft tissue grafting after ARP (b). Materials and Methods Patients in need of a single or multiple unit fixed reconstruction in the premaxilla were included in this prospective case series. After tooth extraction, sockets were grafted with C-DBBM and sealed with a S-CTG. Cone beam computed tomography slides taken before tooth extraction and 4 to 6 months after ARP were superimposed to measure changes in bone dimensions and external soft tissue profile. The need for additional hard and soft tissue grafting was registered. Implants were evaluated at 1 year. Patient-reported outcomes were registered on a 100 mm visual analogue scale at suture removal and 1 year following ARP. Results Nineteen teeth (10 with intact sockets, 9 with nonintact sockets) in 14 patients (11 females; mean age 34) were extracted and treated with the abovementioned protocol. Volume loss could not be prevented and mainly occurred at the buccal aspect. Maximum horizontal bone resorption was 1.27 mm and maximum horizontal shrinkage of the soft tissue profile amounted to 0.87 mm, both at the most cervical aspect. Additional GBR was necessary in two sites with a nonintact buccal bone wall. The need for additional soft tissue grafting was moderate in sites with intact (3/10) and high in nonintact sockets (6/9). Implants demonstrated favorable clinical and esthetic outcomes. Pain intensity and patient satisfaction were 17 and 94, respectively. Conclusion Alveolar ridge preservation was not able to prevent relevant tissue changes. However, implants could be installed as planned. Although the application of a S-CTG partly compensated for the buccal bone loss, the need for additional soft tissue grafting was still moderate in intact sockets and high in nonintact sockets

A Randomized Controlled Trial Comparing Collagen Matrix to Hemostatic Gelatin Sponge as Socket Seal in Alveolar Ridge Preservation

(1) Objectives: This study aimed to compare a collagen matrix to a hemostatic gelatin sponge as a socket seal in alveolar ridge preservation (ARP). (2) Methods: Systemically healthy patients planned for ARP at two sites with more than 50% of the buccal bone wall remaining after tooth extraction were eligible for inclusion. ARP involved socket grafting using collagen-enriched deproteinized bovine bone mineral. Sites were then randomly assigned to the test group (collagen matrix) or the control group (hemostatic gelatin sponge). The primary outcome was soft tissue thickness in the center of the site at 4 months, analyzed on cone-beam computed tomography. Secondary outcomes included the buccal and lingual soft tissue heights, horizontal bone loss, buccal soft tissue profile changes, wound dimensions, and Socket Wound Healing Score (SWHS). (3) Results: In total, 18 patients (12 females, 6 males) with a mean age of 57.3 years (SD 11.1) were included. Four months after ARP, the soft tissue thickness in the center of the site amounted to 2.48 mm (SD 0.70) in the test group and 1.81 mm (SD 0.69) in the control group. The difference of 0.67 mm (95% CI: 0.20–1.14) in favor of the collagen matrix was statistically significant (p p = 0.034). A trend favoring the collagen matrix was found for the lingual soft tissue height (p = 0.066). No significant differences between the groups in terms of horizontal bone loss, buccal soft tissue profile changes, wound dimensions, and the SWHS were found. (4) Conclusions: The absence of significant differences in hard tissue outcomes suggests that both the collagen matrix and hemostatic gelatin sponge effectively sealed the extraction socket and supported bone preservation. However, the collagen matrix better maintained soft tissue dimensions. The clinical relevance of this finding with respect to the necessity for adjunctive soft tissue augmentation at the time of implant placement is yet to be studied

A multi-centre randomized controlled trial comparing connective tissue graft with collagen matrix to increase buccal soft tissue thickness : a cone-beam CT analysis

(1) Aim: a cross-linked porcine-derived collagen matrix (CMX) has been developed for soft tissue augmentation. Although this grafting material does not require a second surgical site, recent findings have indicated deeper pockets, more marginal bone loss and more midfacial recession in the short term when compared to connective tissue graft (CTG). Hence, the aim of the present study was to evaluate the safety of CMX based on buccal bone loss over a one-year period. (2) Methods: Patients who were missing a single tooth in the anterior maxilla were included, in whom the failing tooth had been removed at least 3 months prior and who presented a horizontal mucosa defect. All sites had a bucco-palatal bone dimension of at least 6 mm as assessed on Cone-Beam Computed Tomography (CBCT) to ensure complete embedding of an implant by bone. All patients received a single implant and an immediate implant restoration using a full digital workflow. Sites were randomly allocated to the control (CTG) or test group (CMX) to increase buccal soft tissue thickness. All surgeries were performed by means of full thickness mucoperiosteal flap elevation, placing CTG and CMX in contact with the buccal bone wall. Safety was assessed by evaluating the impact of CTG and CMX on buccal bone loss over a one-year period using superimposed CBCT scans. (3) Results: thirty patients were included per group (control: 50% females, mean age 50; test: 53% females, mean age 48) and 51 (control: 25; test: 26) could be analyzed for buccal bone loss. At 1 mm apical to the implant-abutment interface (IAI), most horizontal resorption was found pointing to 0.44 mm in the control group and 0.59 mm in the test group. The difference of 0.14 mm (95% CI: -0.17-0.46) was not statistically significant (p = 0.366). At 3 mm and 5 mm apical to the IAI, the difference between the groups was 0.18 mm (95% CI: -0.05-0.40; p = 0.128) and 0.02 mm (95% CI: -0.24-0.28; p = 0.899), respectively. Vertical buccal bone loss amounted to 1.12 mm in the control group and 1.14 mm in the test group. The difference of 0.02 mm (95% CI: -0.53-0.49) was not statistically significant (p = 0.926). (4) Conclusions: In the short term, soft tissue augmentation with CTG or CMX results in limited buccal bone loss. CMX is a safe alternative to CTG. Longer follow-up is needed to assess the impact of soft tissue augmentation on buccal bone