Comparing clinical outcomes of immediate implant placement with early implant placement in healthy adult patients requiring single-tooth replacement in the aesthetic zone: a systematic review and meta-analysis of randomised controlled trials.

BACKGROUND: The aim of this systematic review and meta-analysis was to assess the clinical efficacy of the immediate implant placement (IIP) protocol in the aesthetic zone with early dental implant placement (EIP) protocol. METHODS: Electronic databases MEDLINE (via OVID), EMBASE (via OVID), ISI Web of Science core collection, Cochrane, SCOPUS, and Google Scholar were searched for the studies comparing the two clinical protocols. Randomised controlled trials were included. Cochrane Risk of Bias tool (ROB-2) was used to assess the quality of included students. RESULTS: A total of six studies were selected. Implant failure was observed at 3.84%, 9.3%, and 4.45% in three studies while in the other studies, no implant failure was reported. Meta-analysis of four studies showed no statistically significant difference in the vertical bone levels between IIP and EIP (148 patients), mean difference (MD)0.10 [95% CI: -0.29 to 0.091.32] P > 0.05. Meta-analysis of two studies showed the probing depth between IIP versus EIP was not significantly different (100 patients), mean difference(MD)-0.00 [95% CI; -0.23 to 0.23]; P > 0.05. The pink aesthetic score (PES) was improved in EIP as compared to IIP with a statistically significant difference (P < 0.05). CONCLUSION: The available evidence supports the clinical efficacy of the IIP protocol. Present findings indicate aesthetics and clinical results of immediate implant placement protocol are comparable to early and delayed placement protocols. Therefore, future research with long-term follow-up is warranted.

PLACEMENT OF PREFORMED METAL CROWNS ON CARIOUS PRIMARY MOLARS BY DENTAL HYGIENE/THERAPY VOCATIONAL TRAINEES IN SCOTLAND: A SERVICE EVALUATION ASSESSING PATIENT AND PARENT SATISFACTION.

BACKGROUND: The utility and acceptability of preformed metal crowns (PMC) for management of carious primary molars has been established in the literature and published guidance. The role of dental hygienist and therapists (DHT) in the evolving team model in primary care has been recognised as requiring further investigation. The importance of patient and parental acceptance is acknowledged in recent healthcare research. METHOD: This study focuses on patient and parent acceptance of preformed metal crowns placed by DHTs. Prescription format is investigated and the availability of bitewing radiographs considered. Reflective assignments at the end of training gave an indication of DHTs views on increased professional autonomy and the issue of direct access. Patient and parent satisfaction following placement of PMCs by DHT vocational trainees (DHTVT) were evaluated. Data was collected in two audit rounds from 2013 to 2014 using a 'faces' scale for children and a Likert scale for parents following placement of PMCs on carious primary molars. RESULTS: 133 PMCs were placed (110 children) by 10 DHTVTs over an eight-month period. Overall, radiographs were available for 10.5% of cases. The data showed high levels of patient and parent acceptance of the use of PMCs. CONCLUSIONS: Low availability of radiographs may represent a missed diagnostic opportunity. PMC placement by DHTVTs resulted in high patient and parent satisfaction, comparable to other studies. Although caries has been declining over the last decade in Scotland, evidence shows that inequalities and a social gradient in experience of caries in children remain. There is a need for tools and strategies for the prevention, recognition, risk assessment, diagnosis, and management of caries in the primary dentition. These must be accessible, acceptable to children and their parents/carers, cost effective, affordable and applicable in the primary care general dental practice environment where most families are likely to be registered. The emerging theme of dentistry being provided in a team model with dental care professionals (DCPs) taking on an expanded role is under continuing review following the General Dental Council (GDC) announcements on 'direct access'. The Scottish Dental Hygiene and Therapy Vocational Training (DHTVT) programme is a one-year, elective, post-qualification training programme for Dental Hygiene and Therapy graduates run by NHS Education for Scotland (NES). In 2013-2014, DHTVTs were employed across six Scottish health board areas in hospital, salaried and independent settings in urban and rural locations. The elements of the programme involve a blend of clinical mentoring, web-based learning, case presentations, critical reading, reflective assignments and face-to-face theoretical and practical teaching across a number of modules. The aim of this project was to collect data to indicate patient and parental response following the placement of PMCs, collect data on the use of radiographs in children having PMCs placed and to investigate the role of dental therapists in the dental team. The data, once collated, was presented to DHTVTs to inform reflection on the management of carious primary molars and to raise awareness of issues relating to cost effectiveness of providing treatment in a primary care environment and critically appraise perceived barriers to the use of PMCs in the treatment of carious primary molars. Collated data has been presented to trainers in future cohorts to inform discussion amongst the group of trainers at induction days around dental team working, effective detection, diagnosis, risk assessment and prescription to DHTs.

The water method significantly enhances detection of diminutive lesions (adenoma and hyperplastic polyp combined) in the proximal colon in screening colonoscopy - data derived from two RCT in US veterans.

PURPOSE: Emerging data indicate a colonoscopist-controlled method is needed to avoid missing proximal colon pre-malignant lesions. Screening colonoscopy does not prevent all proximal colon cancers. Even diminutive lesions in the proximal colon harbor dysplasia. In addition to adenomas (presumptive cancer precursors), recent proposals to reevaluate proximal colon hyperplastic polyps as serrated polyps which could be pre-malignant or harbingers of interval neoplasia dramatize the importance of attending to these lesions. The finding that the water method increased yield of proximal diminutive adenomas prompted assessment of the hypothesis that the water method increases yield of all proximal diminutive lesions (adenoma and hyperplastic polyp) in screening cases. METHODS: Two RCT assessed the water method with primary outcome of completion of unsedated colonoscopy when the option of scheduled, unsedated or sedation on demand was used. Diminutive (<10 mm) lesions proximal to the splenic flexure were tracked. RESULTS: In screening cases, 31% and 6% of the water and air group had at least one proximal diminutive lesion (p=0.0012). Regression analysis revealed withdrawal time, method and volume of water used were significant predictors of proximal diminutive lesions. Effect of the water method on detection of proximal diminutive lesions was independent of age, body mass index, endoscopist, sedation, cecal intubation rate, bowel cleanliness score on withdrawal and total procedure time. LIMITATION: Male subject predominance, analysis of secondary outcomes of pooled RCT data. CONCLUSION: The hypothesis that the water method effectively enhances proximal diminutive lesion detection in screening colonoscopy in diverse clinical settings should be tested.

A proof-of-principle, prospective, randomized, controlled trial demonstrating improved outcomes in scheduled unsedated colonoscopy by the water method.

BACKGROUND: An observational study in veterans showed that a novel water method (water infusion in lieu of air insufflation) enhanced cecal intubation and willingness to undergo a repeat scheduled unsedated colonoscopy. OBJECTIVE: To confirm these beneficial effects and significant attenuation of discomfort in a randomized, controlled trial (RCT). DESIGN: Prospective RCT, intent-to-treat analysis. SETTING: Veterans Affairs ambulatory care facility. PATIENTS: Veterans undergoing scheduled unsedated colonoscopy. INTERVENTIONS: During insertion, the water and traditional air methods were compared. MAIN OUTCOME MEASUREMENTS: Discomfort and procedure-related outcomes. RESULTS: Eighty-two veterans were randomized to the air (n = 40) or water (n = 42) method. Cecal intubation (78% vs 98%) and willingness to repeat (78% vs 93%) were significantly better with the water method (P < .05; Fisher exact test). The mean (standard deviation) of maximum discomfort (0 = none, 10 = most severe) during colonoscopy was 5.5 (3.0) versus 3.6 (2.1) P = .002 (Student t test), and the median overall discomfort after colonoscopy was 3 versus 2, P = .052 (Mann-Whitney U test), respectively. The method, but not patient characteristics, was a predictor of discomfort (t = -1.998, P = .049, R(2) = 0.074). The odds ratio for failed cecal intubation was 2.09 (95% CI, 1.49-2.93) for the air group. Fair/poor previous experience increased the risk of failed cecal intubation in the air group only. The water method numerically increased adenoma yield. LIMITATIONS: Single site, small number of elderly men, unblinded examiner, possibility of unblinded subjects, restricted generalizability. CONCLUSIONS: The RCT data confirmed that the water method significantly enhanced cecal intubation and willingness to undergo a repeat colonoscopy. The decrease in maximum discomfort was significant; the decrease in overall discomfort approached significance. The method, but not patient characteristics, was a predictor of discomfort. (Clinical trial registration number NCT00747084).

Impact of a novel water method on scheduled unsedated colonoscopy in U.S. veterans.

BACKGROUND: Intermittent warm-water infusion in lieu of air insufflation permitted 52% of patients who accepted sedation on demand to complete colonoscopy without sedation. OBJECTIVE: To test the hypothesis that the water method enhances cecal intubation and increases the proportion of patients who report willingness to repeat a scheduled unsedated colonoscopy. DESIGN: Observational study. PATIENTS: Two consecutive groups of veterans. INTERVENTIONS: From June 2005 to May 2006, the usual air insufflation method was used to aid colonoscope insertion. From June 2006 to October 2007, the water method was used. MAIN OUTCOME MEASUREMENTS: Cecal intubation; report of willingness to repeat unsedated colonoscopy. RESULTS: Sixty-two and 63 veterans were examined by the air method and the water method, respectively. Intention-to-treat analysis revealed that the cecal intubation rate with the water method (97% [61/63]) was significantly higher than that with the air method (76% [47/62]). The proportion of patients who reported willingness to repeat unsedated colonoscopy was significantly higher with the water method (90% [57/63]) compared with the air method (69% [43/62]). LIMITATIONS: Single site, nonrandomized, unblinded, small number of elderly male veterans. CONCLUSION: The effects of the water method in the group for scheduled unsedated colonoscopy were sufficiently provocative to warrant calling for their confirmation by a randomized controlled trial.

Unsedated colonoscopy: time to revisit this option?

BACKGROUND: Access to potentially life-saving screening colonoscopy is limited by the high cost of sedation. We explored the practicability of having supervised trainees perform unsedated colonoscopies. METHOD: A nursing shortage at our Veterans Administration gastroenterology training program necessitated discontinuing sedated colonoscopy. We offered the procedure without sedation to restore local access to screening colonoscopy. RESULTS: From September 2002 to June 2005, 145 of 483 patients accepted the unsedated option. The procedure was done by second-year gastroenterology (GI) fellows who had performed about 100 sedated colonoscopies in their first year of training. Cecal intubation was achieved in 81% of 138 well purged patients without obstructive lesions. Implementation obviated the need for 2 registered nurses, the escort requirement, and postprocedure activity restriction. It also eliminated sedation-related complications. CONCLUSION: This report confirms the feasibility of unsedated colonoscopy performed by supervised trainees. The unsedated option minimizes direct and indirect costs of colonoscopy. Describing unsedated screening colonoscopy to patients as a "sedation risk-free" procedure encouraged them to consider the benefits. We recommend that future studies test primary care providers' willingness to inform patients of the feasibility of this nonstandard option, and perhaps reshape the practice of colonoscopy for colorectal cancer screening.