- Email: [email protected]
Quality assessment of systematic reviews regarding immediate placement of dental implants into infected sites: An overview
SYSTEMATIC REVIEW
Quality assessment of systematic reviews regarding immediate placement of dental implants into infected sites: An overview Olavo B. de Oliveira-Neto,a Fabiano Timbó Barbosa, MD, MS, PhD,b Célio Fernando de Sousa-Rodrigues, MD, MS, PhD,c and Fernando José C. de Lima, DDS, MSd Systematic reviews (SRs) ABSTRACT represent a type of research that Statement of problem. With the increased number of published systematic reviews and in view of analyzes all available scientific their wide clinical applicability, these studies must be carefully assessed before professionals begin reports concerning a specific to use their recommendations in daily practice, and above all, the methodological quality of this topic in order to synthesize evstudy design must be considered. In implant dentistry, one topic that has been arousing particular interest is the immediate placement of dental implants into infected sites. idence about the effectiveness and effects of interventions. Purpose. The purpose of this systematic review was to determine the methodological quality of Systematic methods are used to systematic reviews that evaluated the immediate placement of dental implants into infected sites. avoid bias and to allow a more Material and methods. A systematic search was performed by 2 independent reviewers of objective analysis of results, PubMed, LILACS, and ISI Web of Knowledge up to March 2016. All selected articles were published thereby facilitating a conclusive in the English language. Systematic reviews of original papers that assessed the immediate synthesis regarding a given placement of dental implants into infected sites were eligible for the overview. Narrative reviews, randomized clinical trials, and case reports were excluded. Methodological quality assessment was intervention.1-3 performed using A Measurement Tool to Assess Systematic Reviews. However, with the increased number of published Results. Of the 5 selected systematic reviews, 3 were low methodological quality and 2 were SRs and in view of their wide assessed as moderate. None were high methodological quality. The first systematic review of the topic was published in 2010, and the most recent, published in 2015, was the only one that perapplicability in clinical practice, formed meta-analysis. these studies must be carefully assessed before professionals Conclusions. The systematic reviews that assessed the immediate placement of dental implants into infected sites were assessed as low or moderate methodological quality. The topic focus rebegin to follow their recommains controversial because the implant survival rate, the main outcome considered for the implant mendations in daily clinical placement prognosis, presents contradictory results. (J Prosthet Dent 2016;-:---) practice. Above all, the methodological quality of this type of study must be considered.4 In this context, the overassessing the methodological quality of SRs.6 This tool view emerges, a kind of research for the purpose of was evaluated and externally validated and was considanalyzing the main sources of bias of SRs to improve the ered a reliable and easily usable instrument.7 It has scope, quality of this kind of publication and to inform readers feasibility, and reliability, qualities not found in existing how failures can influence the results.5 instruments.8,9 A Measurement Tool to Assess Systematic Reviews In implant dentistry, a topic that has been arousing (AMSTAR) is an instrument developed for the purpose of particular interest is the immediate placement of dental
a Predoctoral student, Faculty of Dentistry, Federal University of Alagoas, Alagoas, Brazil; and Monitor student, Sector of Human Anatomy, Institute of Health and Biological Sciences, Federal University of Alagoas, Alagoas, Brazil. b Adjunct Professor I, Anesthesiology and Basis for Surgical Technique, Faculty of Medicine, Federal University of Alagoas, Alagoas, Brazil. c Associate Professor IV, Sector of Human Anatomy, Institute of Health and Biological Sciences, Federal University of Alagoas, Alagoas, Brazil. d Assistant Professor IV, Sector of Human Anatomy, Institute of Health and Biological Sciences, Federal University of Alagoas, Alagoas, Brazil.
THE JOURNAL OF PROSTHETIC DENTISTRY
1
2
Volume
Clinical Implications The present overview is important for clinical practice because none of the included studies had high methodological quality, and these studies could be used to formulate and establish important surgical decisions. This could lead to loss of time, increased costs, and, particularly, adverse effects on the health of patients with regard to the immediate placement of dental implants into infected sites.
implants into infected sites.10 Conventionally, the compromised tooth is extracted and the dental socket allowed to heal for a period of several months to 1 year. However, many patients seek to shorten the period between tooth extraction and implant placement, if possible at the same session, reducing the number of surgical steps.11 Other factors related to the decision to place the implant immediately include physiological alveolar bone resorption and the surgeon’s concern regarding local and systemic risks of infection and associated failures in osseointegration if the tooth socket remains infected even after alveolar disinfection.12,13 Therefore, the present overview was conducted to answer the following focused question: What is the quality of systematic reviews that assessed the immediate placement of dental implants into infected sites? MATERIALS AND METHODS The research was performed at the library of the Federal University of Alagoas and is an overview, a systematic review performed for the purpose of assessing other systematic reviews. Because the overview is a kind of research whose sample is systematic review articles, only papers and not human beings are involved. Thus, it does not require ethics committee approval and free informed consent. SRs of original papers that assessed the immediate placement of dental implants into infected sites were eligible for the overview. Narrative reviews, randomized clinical trials, and case reports were excluded. The search for SRs was performed by 2 independent reviewers (O.B. and F.T.) using PubMed (from 1960 to March 2016), LILACS (from 1982 to March 2016), and ISI Web of Knowledge to March 2016. The following search strategy was used in PubMed: (“classification”[MeSH terms] OR “classification”[all fields] OR “systematic”[all fields]) AND (“dental implants”[MeSH terms] OR (“dental”[all fields] AND “implants”[all fields]) OR “dental implants”[all fields] OR (“dental”[all fields] AND “implant”[all fields]) OR “dental implant”[all fields]) AND (“tooth socket”[MeSH terms] OR (“tooth”[all fields] AND “socket”[all fields]) OR “tooth socket”[all fields]). The terms “systematic” and “dental implant” THE JOURNAL OF PROSTHETIC DENTISTRY
-
Issue
-
were used in LILACS, and the terms “systematic”, “dental implant”, and “tooth socket” were used in ISI Web of Knowledge. To select articles of relevance, the same reviewers screened the titles and/or abstracts of the obtained results from the online databases. The articles that were initially selected were read fully. The references of the selected articles were also searched for papers of potential interest. We did not exclude languages from the selection. However, all articles included in the overview were published in the English language. Once the articles had been selected, the 2 reviewers read the selected SRs fully and performed the quality assessment of these reviews with the use of AMSTAR. This tool is composed of an 11-item questionnaire that focuses on the methodological quality of SRs. AMSTAR questions were answered by reviewers with “Yes”, “No”, “Can’t answer”, and “Not Applicable.: Can’t answer was chosen when the item was not reported by the authors, and Not Applicable was chosen when the item was not relevant, such as when the meta-analysis could not be performed or was not attempted by the authors. The final methodological quality of the review was high when there were 9 or more Yes answers; moderate when there were between 5 and 8 Yes answers; or low when there were 4 or fewer Yes answers. Any disagreements between reviewers were resolved by means of meeting and discussion in order to establish a consensus. In situations where any disagreement persisted, a third reviewer (F.J.C.) was consulted. The primary outcome of this research was the methodological quality of SRs regarding the immediate placement of dental implants into infected sites (Table 1). Secondary outcomes were implant survival rate, follow-up period, and the level of alveolar crest recession (Table 2). Data analysis The sample size calculation was not performed because the present research is an overview. The primary outcome (quality of systematic reviews) was described according to the quality established by the use of AMSTAR as high, moderate, or low. Secondary outcomes were described as follows: implant survival rate in percentage, follow-up period in months, and level of alveolar crest recession in millimeters. RESULTS A total of 102 publications of potential interest were initially identified in PubMed, 34 in ISI Web of Knowledge, and 22 in LILACS. The titles and abstracts of these publications were screened, and 17 papers were selected for full reading (11 in PubMed, 6 in ISI Web of Knowledge, and 0 in LILACS). Twelve articles were excluded because they were duplicates or because they did not fulfill the previously established eligibility criteria. Finally, de Oliveira-Neto et al
-
2016
3
Table 1. Methodological quality assessment of each included study using AMSTAR Waasdorp et al,14 2010
Álvarez-Camino et al,15 2013
1. Was an “a priori” design provided?
No
No
No
No
No
2. Was there duplicated study selection and data extraction?
Yes
No
Yes
Yes
Yes
AMSTAR Question
Lee et al,17 2015
Chrcanovic et al,16 2015
Zhao et al,18 2016
3. Was a comprehensive literature search performed?
No
Yes
No
No
Yes
4. Was the status of publication (i.e., gray literature) used as an inclusion criterion?
Yes
Yes
Yes
Yes
Yes
5. Was a list of studies (included and excluded) provided?
No
No
Yes
No
Yes
6. Were the characteristics of the included studies provided?
Yes
No
Yes
Yes
No
7. Was the scientific quality of the included studies assessed and documented?
No
No
Yes
No
Yes
8. Was the scientific quality of the included studies used appropriately in formulating conclusions?
No
No
No
No
No
9. Were the methods used to combine the findings of studies appropriate?
Not Applicable
Not Applicable
Not Applicable
Not Applicable
Yes
10. Was the likelihood of publication bias assessed?
Not Applicable
Not Applicable
Not Applicable
Not Applicable
Yes
Yes
No
Yes
Yes
Yes
04/11
02/11
06/11
04/11
08/11
Low
Low
Moderate
Low
Moderate
11. Was the conflict of interest stated? Total Methodological quality
Table 2. Secondary outcomes of present overview considering outcomes reported at included systematic reviews Follow-Up Period (mo)
% Implant Survival Rate
Level of alveolar crest recession (mm)
7-72
92.00-100.00
NR
NR
NR
NR
Lee et al,17 2015
12-60
92.00-100.00
0.17-0.53
Chrcanovic et al,16 2015
12-93
85.70-100.00
0.41-1.90
Zhao et al,18 2016
12-93
94.44-100.00
0.20-0.86
Study Waasdorp et al,14 2010 Álvarez-Camino et al,15 2013
NR, not reported.
5 SRs were selected for the overview.14-18 These data are summarized in Figure 1. Of the 5 selected SRs, 3 were low methodological quality, 2 had their methodological quality assessed as moderate, and none had high methodological quality. The first systematic review focusing on the topic was published in 2010 and the most recent one, published in 2015, was the only one that performed meta-analysis (Table 3). Despite the SRs making their search strategies available in the electronic databases, none of them made available the registered protocol of the SRs. Thus, none of the studies obtained a Yes answer for the number 1 AMSTAR question. Similarly, none of the publications obtained a Yes answer for the number 8 AMSTAR question for none had an explicit declaration in the conclusion section of the review that the methodological rigor and scientific quality of studies were considered. With the exception of the study by Zhao et al,18 no study performed meta-analysis; therefore, the other studies received the answer Not Applicable for AMSTAR questions 9 and 10. The secondary outcomes of the overview are described in Table 2. All included studies, except for 1,15 de Oliveira-Neto et al
had as the primary outcome the implant survival rate. The level of alveolar crest recession was the secondary outcome in all studies except for those by Waasdorp et al14 and Álvarez-Camino et al.15 In the study by Lee et al,17 the reported outcomes were only for the implants immediately placed into sockets with periapical lesions. In the same study, the minimum value of 0.17 mm was in the mesial alveolar crest, and the maximum value of 0.53 mm was in the distal alveolar crest. Waasdorp et al,14 Álvarez-Camino et al,15 and Chrcanovic et al16 performed studies in humans and animals. However, the outcomes reported in Table 2 refer only to the human-related data; the animal-related outcomes were not reported. The lower and higher values for the levels of alveolar crest recession reported by Chrcanovic et al16 were in the mesial alveolar crest and only for the test groups (with infected sites). For Zhao et al,18 the minimum value of 0.20 ±0.4 mm was in the mesial alveolar crest, and the alveolar crest assessed for the maximum value of 0.86 mm was not reported. Also, the standard deviation was not reported, and only the mean values are reported in Table 2. DISCUSSION According to Shea et al,6 high methodological quality is a prerequisite for a valid and adequate interpretation of the results of a review. The lowest score obtained for the SRs assessed with AMSTAR was 2 of 11, and the highest was 8 of 11. Also obtained were 2 scores of 4 of 11 and 1 score of 6 of 11 (Table 1). None of the SRs, therefore, had high methodological quality, and 3 of the 5 existing reviews about the theme had low methodological quality according to the AMSTAR assessment. The overview focused on assessment of the methodological quality of the studies and not on the quality of the
THE JOURNAL OF PROSTHETIC DENTISTRY
4
Volume
Search
PubMed (n = 102)
ISI Web of Knowledge (n = 34)
-
Issue
-
LILACS database (n = 22)
Reasons: • Duplicate • Narrative review • Randomized clinical trial • Case report
Articles excluded after reading title and/or abstract (n = 141) Eligibility Excluded after reading full article (n = 12)
Included
Systematic reviews included in the overview (n = 5)
Figure 1. Search process, eligibility, and final selection of systematic reviews for overview. Table 3. Studies eligible for overview
Study ID
Study Title
Journal
Methodological Qualitya
Main Conclusions
12 (8 in humans The placement of an immediate implant in infected sites is a viable and predictable and 4 in treatment, as suggested by limited data of animals) studies in humans and animals
Waasdorp et al,14 2010
Immediate placement of implants into infected sites: a systematic review of the literature
Journal of Periodontology
Low
Álvarez-Camino et al,15 2013
Immediate implants placed in fresh sockets associated to periapical infectious processes. A systematic review
Medicina Oral, Patología Oral y Cirugía Bucal
Low
Lee et al,17 2015
Survival analysis and other clinical outcomes of immediate implant placement in sites with periapical lesions: systematic review
The International Journal of Oral and Maxillofacial Implants
Moderate
Chrcanovic et al,16 2015
Immediate placement of implants into infected sites: a systematic review
Clinical Implant Dentistry and Related Research
Low
Clinical Oral Implants Research
Moderate
Zhao et al,18 2016 Immediate dental implant placement into infected vs noninfected sockets: a meta-analysis
Number of Included Studies
16b
Is very difficult to state categorically that the placement of an immediate implant in sockets associated to endoperiodontal infection can be considered as a reliable treatment, considering the little literature available about this topic.
3 (All in humans)
Based on the limited evidence available, the placement of an immediate implant in infected sites has successes rates and clinical outcomes comparable with other modalities of implant treatment.
28 (21 in humans and 7 in animals)
High success rates and normal changes in the bone level support the hypothesis that an immediate implant could be successfully osseointegrated even in the presence of endodontic or periodontal lesions if adequate clinical procedures are performed previously to implant placement
7 (All in humans)
Immediate implant placement into infected sites might increase the failure risk of the implant, compared with an implant placed into a healthy site.
a
Methodological quality of studies was determined through assessment with AMSTAR. bThis study used systematic reviews in humans and animals; however, specific quantity of studies in humans and animals was not clearly reported. AMSTAR, A Measurement Tool to Assess Systematic Reviews.
report. According to Sequeira-Byron et al,19 an important difference exists between the methodology driving a review and how well it was reported.19 A review may have followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement,20 a 27-item checklist which helps authors to improve the quality of the report of their SRs and meta-analysis, and yet not have high methodological quality, such as the studies of Lee et al,17 Chrcanovic et al,16 and Zhao et al.18 In the study by Zhao et al,18 which had the highest methodological quality score (8 of 11 according to
THE JOURNAL OF PROSTHETIC DENTISTRY
AMSTAR), the authors reported the values of implant failure rate in percentage. However, we inserted in Table 2 the minimum and maximum values for the implant survival rate. The authors of this study were consulted by e-mail and acknowledged the existence of typographical errors in Table 1 of their study (Characteristics of studies included in meta-analysis) and that the term “Failure Rate” in that table should be replaced by “Survival Rate” (of the implant). The main conclusion of this meta-analysis, which differs from the conclusions of the other 4 SRs regarding the focus theme (Table 3), was
de Oliveira-Neto et al
-
2016
supported by a risk ratio (RR) of 2.16 (95% confidence limits: 0.97, 4.80) and without statistical significance (P=.058). This RR was calculated for the immediate placement of dental implants into infected sockets compared with the immediate placement of dental implants into noninfected sockets. All studies included in the present overview, except for Waasdorp et al14 and Álvarez-Camino et al,15 had as secondary outcomes the recession of the alveolar crest. Considering values reported in Table 2, one can observe that such values of recession are minimum, with the maximum value of the range of 2 studies17,18 below 1 mm. Only in the study by Chrcanovic et al16 was the maximum range value close to 2 mm. The same maximum values reported by the authors regarding the immediate placement of dental implants into infected sites are insignificant from the clinical point of view, and this minimum recession could have occurred as a consequence of the surgical protocol chosen to install the implant. Zhao et al18 performed meta-analysis for the aforementioned outcome (the recession of the alveolar crest), which did not show statistical significance (P=.17; 95% confidence interval). The present overview is important for clinical practice because none of the included studies had high methodological quality and these studies could be used to formulate and establish important surgical decisions, which could lead to loss of time, increased costs and, especially, adverse effects on the patient’s health regarding the immediate placement of dental implants into infected sites. The reasons for dental implant failure reported in the studies need to be considered. Considering the causes of retrograde periimplantitis,21 did the surgeon follow the protocols for alveolar disinfection before the immediate implant placement, and were patient-related risk factors such as smoking, alcohol use, and diabetes considered? Did the surgeon adequately plan the occlusion of the patient or was the implant placed in premature contact? Were the hygiene habits of the patient considered to prevent periodontal disease and consequently implant instability, which could lead to future implant failure? A great divergence was found among the included studies on the topic “periapical infection.” Future primary studies that assess “periapical infection” should investigate beyond the clinical diagnosis. The quantitative and qualitative microbiological diagnosis must also be known. We suggest that future primary studies perform a microbiological analysis as eligibility criteria in order to avoid confusion regarding the kind of periapical infection present before the immediate implant placement or even whether an infection was actually present. CONCLUSIONS The SRs that assessed the immediate placement of dental implants into infected sites had a methodological quality
de Oliveira-Neto et al
5
assessed as low or moderate. The focused topic remains controversial because the implant survival rate, the main outcome considered for the implant placement prognosis, presents contradictory results and conclusions. REFERENCES 1. Linde K, Willich SN. How objective are systematic reviews? Differences between reviews on complementary medicine. J R Soc Med 2003;96:17-22. 2. Lau J, Ioannidis JPA, Schmid CH. Summing up evidence: one answer is not always enough. Lancet 1998;351:123-7. 3. Gopalakrishnan S, Ganeshkumar P. Systematic reviews and meta-analysis: understanding the best evidence in primary healthcare. J Family Med Prim Care 2013;2:9-14. 4. Shea BJ, Grimshaw JM, Wells GA, Boers M, Andersson N, Hamel C, Porter AC, et al. Development of AMSTAR: a measurement tool to assess the methodological quality of systematic reviews. BMC Med Res Methodol 2007 15;7:10. 5. Barbosa FT, Castro AA, Miranda CT. Anestesia neuroaxial comparada à anestesia geral para procedimentos na metade inferior do corpo: revisão sistemática de revisões sistemáticas. Rev Bras Anestesiol 2012;62:235-43. 6. Shea BJ, Hamel C, Wells GA, Bouter LM, Kristjansson E, Grimshaw J, et al. AMSTAR is a reliable and valid measurement tool to assess the methodological quality of systematic reviews. J Clin Epidemiol 2009;62:1013-20. 7. Shea BJ, Bouter LM, Peterson J, Boers M, Andersson N, et al. External validations of A Measurement Tool to Assess Systematic Reviews (AMSTAR). PLoS One 2007;2:e1350. 8. Oxman AD, Guyatt GH. Validation of an index of the quality of review articles. J Clin Epidemiol 1991;44:1271-8. 9. Sacks H, Berrier J, Reitman D, Ancona-Berk VA, Chalmers TC. Meta-analyses of randomized controlled trials. N Engl J Med 1987;316:450-5. 10. Fugazzotto P. A retrospective analysis of immediately placed implants in 418 sites exhibiting periapical pathology: results and clinical considerations. Int J Oral Maxillofac Implants 2012;27:194-202. 11. Esposito M, Grusovin MG, Polyzos IP, Felice P, Worthington HV. Timing of implant placement after tooth extraction: immediate, immediate-delayed or delayed implants? A Cochrane systematic review. Eur J Oral Implantol 2010;3:189-205. 12. Rosenquist B, Grenthe B. Immediate placement of implants into extraction sockets: Implant survival. Int J Oral Maxillofac Implants 1996;11:205-9. 13. Jofre J, Valenzuela D, Quintana P, Asenjo-Lobos C. Protocol for immediate implant replacement of infected teeth. Implant Dent 2012;21:287-94. 14. Waasdorp JA, Evian CI, Mandracchia M. Immediate placement of implants into infected sites: a systematic review of the literature. J Periodontol 2010;81: 801-8. 15. Álvarez-Camino JC, Valmaseda-Castellón E, Gay-Escoda C. Immediate implants placed in fresh sockets associated to periapical infectious processes. A systematic review. Med Oral Patol Oral Cir Bucal 2013;18:780-5. 16. Chrcanovic BR, Martins MD, Wennerberg A. Immediate placement of implants into infected sites: a systematic review. Clin Implant Dent Relat Des 2015;17(suppl 1):e1-16. 17. Lee CT, Chuang SK, Stoupel J. Survival analysis and other clinical outcomes of immediate implant placement in sites with periapical lesions: systematic review. Int J Oral Maxillofac Implants 2015;30:268-78. 18. Zhao D, Wu Y, Xu C, Zhang F. Immediate dental implant placement into infected vs. non-infected sockets: a meta-analysis. Clin Oral Implants Res 2016;27:1290-6. 19. Sequeira-Byron P, Fedorowicz Z, Jagannath VA, Sharif MO. An AMSTAR assessment of the methodological quality of systematic reviews of oral healthcare interventions published in the Journal of Applied Oral Science (JAOS). J Appl Oral Sci 2011;19:440-7. 20. Moher D, Liberati A, Telzlaff J, Altman DG; , for the PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 2009;6:e1000097. 21. Nguyenhieu T, Borghetti A, Aboudharam G. Peri-implantitis: from diagnosis to therapeutics. J Investig Clin Dent 2012;3:79-94.
Corresponding author: Dr Olavo Barbosa de Oliveira-Neto Faculty of Dentistry Federal University of Alagoas Campus A.C. Simões. Lourival Melo Mota Ave Tabuleiro dos Martins, Maceió, AL 57072-900 BRAZIL Email: [email protected] Copyright © 2016 by the Editorial Council for The Journal of Prosthetic Dentistry.
THE JOURNAL OF PROSTHETIC DENTISTRY
Quality assessment of systematic reviews regarding immediate placement of dental implants into infected sites: An overview Olavo B. de Oliveira-Neto,a Fabiano Timbó Barbosa, MD, MS, PhD,b Célio Fernando de Sousa-Rodrigues, MD, MS, PhD,c and Fernando José C. de Lima, DDS, MSd Systematic reviews (SRs) ABSTRACT represent a type of research that Statement of problem. With the increased number of published systematic reviews and in view of analyzes all available scientific their wide clinical applicability, these studies must be carefully assessed before professionals begin reports concerning a specific to use their recommendations in daily practice, and above all, the methodological quality of this topic in order to synthesize evstudy design must be considered. In implant dentistry, one topic that has been arousing particular interest is the immediate placement of dental implants into infected sites. idence about the effectiveness and effects of interventions. Purpose. The purpose of this systematic review was to determine the methodological quality of Systematic methods are used to systematic reviews that evaluated the immediate placement of dental implants into infected sites. avoid bias and to allow a more Material and methods. A systematic search was performed by 2 independent reviewers of objective analysis of results, PubMed, LILACS, and ISI Web of Knowledge up to March 2016. All selected articles were published thereby facilitating a conclusive in the English language. Systematic reviews of original papers that assessed the immediate synthesis regarding a given placement of dental implants into infected sites were eligible for the overview. Narrative reviews, randomized clinical trials, and case reports were excluded. Methodological quality assessment was intervention.1-3 performed using A Measurement Tool to Assess Systematic Reviews. However, with the increased number of published Results. Of the 5 selected systematic reviews, 3 were low methodological quality and 2 were SRs and in view of their wide assessed as moderate. None were high methodological quality. The first systematic review of the topic was published in 2010, and the most recent, published in 2015, was the only one that perapplicability in clinical practice, formed meta-analysis. these studies must be carefully assessed before professionals Conclusions. The systematic reviews that assessed the immediate placement of dental implants into infected sites were assessed as low or moderate methodological quality. The topic focus rebegin to follow their recommains controversial because the implant survival rate, the main outcome considered for the implant mendations in daily clinical placement prognosis, presents contradictory results. (J Prosthet Dent 2016;-:---) practice. Above all, the methodological quality of this type of study must be considered.4 In this context, the overassessing the methodological quality of SRs.6 This tool view emerges, a kind of research for the purpose of was evaluated and externally validated and was considanalyzing the main sources of bias of SRs to improve the ered a reliable and easily usable instrument.7 It has scope, quality of this kind of publication and to inform readers feasibility, and reliability, qualities not found in existing how failures can influence the results.5 instruments.8,9 A Measurement Tool to Assess Systematic Reviews In implant dentistry, a topic that has been arousing (AMSTAR) is an instrument developed for the purpose of particular interest is the immediate placement of dental
a Predoctoral student, Faculty of Dentistry, Federal University of Alagoas, Alagoas, Brazil; and Monitor student, Sector of Human Anatomy, Institute of Health and Biological Sciences, Federal University of Alagoas, Alagoas, Brazil. b Adjunct Professor I, Anesthesiology and Basis for Surgical Technique, Faculty of Medicine, Federal University of Alagoas, Alagoas, Brazil. c Associate Professor IV, Sector of Human Anatomy, Institute of Health and Biological Sciences, Federal University of Alagoas, Alagoas, Brazil. d Assistant Professor IV, Sector of Human Anatomy, Institute of Health and Biological Sciences, Federal University of Alagoas, Alagoas, Brazil.
THE JOURNAL OF PROSTHETIC DENTISTRY
1
2
Volume
Clinical Implications The present overview is important for clinical practice because none of the included studies had high methodological quality, and these studies could be used to formulate and establish important surgical decisions. This could lead to loss of time, increased costs, and, particularly, adverse effects on the health of patients with regard to the immediate placement of dental implants into infected sites.
implants into infected sites.10 Conventionally, the compromised tooth is extracted and the dental socket allowed to heal for a period of several months to 1 year. However, many patients seek to shorten the period between tooth extraction and implant placement, if possible at the same session, reducing the number of surgical steps.11 Other factors related to the decision to place the implant immediately include physiological alveolar bone resorption and the surgeon’s concern regarding local and systemic risks of infection and associated failures in osseointegration if the tooth socket remains infected even after alveolar disinfection.12,13 Therefore, the present overview was conducted to answer the following focused question: What is the quality of systematic reviews that assessed the immediate placement of dental implants into infected sites? MATERIALS AND METHODS The research was performed at the library of the Federal University of Alagoas and is an overview, a systematic review performed for the purpose of assessing other systematic reviews. Because the overview is a kind of research whose sample is systematic review articles, only papers and not human beings are involved. Thus, it does not require ethics committee approval and free informed consent. SRs of original papers that assessed the immediate placement of dental implants into infected sites were eligible for the overview. Narrative reviews, randomized clinical trials, and case reports were excluded. The search for SRs was performed by 2 independent reviewers (O.B. and F.T.) using PubMed (from 1960 to March 2016), LILACS (from 1982 to March 2016), and ISI Web of Knowledge to March 2016. The following search strategy was used in PubMed: (“classification”[MeSH terms] OR “classification”[all fields] OR “systematic”[all fields]) AND (“dental implants”[MeSH terms] OR (“dental”[all fields] AND “implants”[all fields]) OR “dental implants”[all fields] OR (“dental”[all fields] AND “implant”[all fields]) OR “dental implant”[all fields]) AND (“tooth socket”[MeSH terms] OR (“tooth”[all fields] AND “socket”[all fields]) OR “tooth socket”[all fields]). The terms “systematic” and “dental implant” THE JOURNAL OF PROSTHETIC DENTISTRY
-
Issue
-
were used in LILACS, and the terms “systematic”, “dental implant”, and “tooth socket” were used in ISI Web of Knowledge. To select articles of relevance, the same reviewers screened the titles and/or abstracts of the obtained results from the online databases. The articles that were initially selected were read fully. The references of the selected articles were also searched for papers of potential interest. We did not exclude languages from the selection. However, all articles included in the overview were published in the English language. Once the articles had been selected, the 2 reviewers read the selected SRs fully and performed the quality assessment of these reviews with the use of AMSTAR. This tool is composed of an 11-item questionnaire that focuses on the methodological quality of SRs. AMSTAR questions were answered by reviewers with “Yes”, “No”, “Can’t answer”, and “Not Applicable.: Can’t answer was chosen when the item was not reported by the authors, and Not Applicable was chosen when the item was not relevant, such as when the meta-analysis could not be performed or was not attempted by the authors. The final methodological quality of the review was high when there were 9 or more Yes answers; moderate when there were between 5 and 8 Yes answers; or low when there were 4 or fewer Yes answers. Any disagreements between reviewers were resolved by means of meeting and discussion in order to establish a consensus. In situations where any disagreement persisted, a third reviewer (F.J.C.) was consulted. The primary outcome of this research was the methodological quality of SRs regarding the immediate placement of dental implants into infected sites (Table 1). Secondary outcomes were implant survival rate, follow-up period, and the level of alveolar crest recession (Table 2). Data analysis The sample size calculation was not performed because the present research is an overview. The primary outcome (quality of systematic reviews) was described according to the quality established by the use of AMSTAR as high, moderate, or low. Secondary outcomes were described as follows: implant survival rate in percentage, follow-up period in months, and level of alveolar crest recession in millimeters. RESULTS A total of 102 publications of potential interest were initially identified in PubMed, 34 in ISI Web of Knowledge, and 22 in LILACS. The titles and abstracts of these publications were screened, and 17 papers were selected for full reading (11 in PubMed, 6 in ISI Web of Knowledge, and 0 in LILACS). Twelve articles were excluded because they were duplicates or because they did not fulfill the previously established eligibility criteria. Finally, de Oliveira-Neto et al
-
2016
3
Table 1. Methodological quality assessment of each included study using AMSTAR Waasdorp et al,14 2010
Álvarez-Camino et al,15 2013
1. Was an “a priori” design provided?
No
No
No
No
No
2. Was there duplicated study selection and data extraction?
Yes
No
Yes
Yes
Yes
AMSTAR Question
Lee et al,17 2015
Chrcanovic et al,16 2015
Zhao et al,18 2016
3. Was a comprehensive literature search performed?
No
Yes
No
No
Yes
4. Was the status of publication (i.e., gray literature) used as an inclusion criterion?
Yes
Yes
Yes
Yes
Yes
5. Was a list of studies (included and excluded) provided?
No
No
Yes
No
Yes
6. Were the characteristics of the included studies provided?
Yes
No
Yes
Yes
No
7. Was the scientific quality of the included studies assessed and documented?
No
No
Yes
No
Yes
8. Was the scientific quality of the included studies used appropriately in formulating conclusions?
No
No
No
No
No
9. Were the methods used to combine the findings of studies appropriate?
Not Applicable
Not Applicable
Not Applicable
Not Applicable
Yes
10. Was the likelihood of publication bias assessed?
Not Applicable
Not Applicable
Not Applicable
Not Applicable
Yes
Yes
No
Yes
Yes
Yes
04/11
02/11
06/11
04/11
08/11
Low
Low
Moderate
Low
Moderate
11. Was the conflict of interest stated? Total Methodological quality
Table 2. Secondary outcomes of present overview considering outcomes reported at included systematic reviews Follow-Up Period (mo)
% Implant Survival Rate
Level of alveolar crest recession (mm)
7-72
92.00-100.00
NR
NR
NR
NR
Lee et al,17 2015
12-60
92.00-100.00
0.17-0.53
Chrcanovic et al,16 2015
12-93
85.70-100.00
0.41-1.90
Zhao et al,18 2016
12-93
94.44-100.00
0.20-0.86
Study Waasdorp et al,14 2010 Álvarez-Camino et al,15 2013
NR, not reported.
5 SRs were selected for the overview.14-18 These data are summarized in Figure 1. Of the 5 selected SRs, 3 were low methodological quality, 2 had their methodological quality assessed as moderate, and none had high methodological quality. The first systematic review focusing on the topic was published in 2010 and the most recent one, published in 2015, was the only one that performed meta-analysis (Table 3). Despite the SRs making their search strategies available in the electronic databases, none of them made available the registered protocol of the SRs. Thus, none of the studies obtained a Yes answer for the number 1 AMSTAR question. Similarly, none of the publications obtained a Yes answer for the number 8 AMSTAR question for none had an explicit declaration in the conclusion section of the review that the methodological rigor and scientific quality of studies were considered. With the exception of the study by Zhao et al,18 no study performed meta-analysis; therefore, the other studies received the answer Not Applicable for AMSTAR questions 9 and 10. The secondary outcomes of the overview are described in Table 2. All included studies, except for 1,15 de Oliveira-Neto et al
had as the primary outcome the implant survival rate. The level of alveolar crest recession was the secondary outcome in all studies except for those by Waasdorp et al14 and Álvarez-Camino et al.15 In the study by Lee et al,17 the reported outcomes were only for the implants immediately placed into sockets with periapical lesions. In the same study, the minimum value of 0.17 mm was in the mesial alveolar crest, and the maximum value of 0.53 mm was in the distal alveolar crest. Waasdorp et al,14 Álvarez-Camino et al,15 and Chrcanovic et al16 performed studies in humans and animals. However, the outcomes reported in Table 2 refer only to the human-related data; the animal-related outcomes were not reported. The lower and higher values for the levels of alveolar crest recession reported by Chrcanovic et al16 were in the mesial alveolar crest and only for the test groups (with infected sites). For Zhao et al,18 the minimum value of 0.20 ±0.4 mm was in the mesial alveolar crest, and the alveolar crest assessed for the maximum value of 0.86 mm was not reported. Also, the standard deviation was not reported, and only the mean values are reported in Table 2. DISCUSSION According to Shea et al,6 high methodological quality is a prerequisite for a valid and adequate interpretation of the results of a review. The lowest score obtained for the SRs assessed with AMSTAR was 2 of 11, and the highest was 8 of 11. Also obtained were 2 scores of 4 of 11 and 1 score of 6 of 11 (Table 1). None of the SRs, therefore, had high methodological quality, and 3 of the 5 existing reviews about the theme had low methodological quality according to the AMSTAR assessment. The overview focused on assessment of the methodological quality of the studies and not on the quality of the
THE JOURNAL OF PROSTHETIC DENTISTRY
4
Volume
Search
PubMed (n = 102)
ISI Web of Knowledge (n = 34)
-
Issue
-
LILACS database (n = 22)
Reasons: • Duplicate • Narrative review • Randomized clinical trial • Case report
Articles excluded after reading title and/or abstract (n = 141) Eligibility Excluded after reading full article (n = 12)
Included
Systematic reviews included in the overview (n = 5)
Figure 1. Search process, eligibility, and final selection of systematic reviews for overview. Table 3. Studies eligible for overview
Study ID
Study Title
Journal
Methodological Qualitya
Main Conclusions
12 (8 in humans The placement of an immediate implant in infected sites is a viable and predictable and 4 in treatment, as suggested by limited data of animals) studies in humans and animals
Waasdorp et al,14 2010
Immediate placement of implants into infected sites: a systematic review of the literature
Journal of Periodontology
Low
Álvarez-Camino et al,15 2013
Immediate implants placed in fresh sockets associated to periapical infectious processes. A systematic review
Medicina Oral, Patología Oral y Cirugía Bucal
Low
Lee et al,17 2015
Survival analysis and other clinical outcomes of immediate implant placement in sites with periapical lesions: systematic review
The International Journal of Oral and Maxillofacial Implants
Moderate
Chrcanovic et al,16 2015
Immediate placement of implants into infected sites: a systematic review
Clinical Implant Dentistry and Related Research
Low
Clinical Oral Implants Research
Moderate
Zhao et al,18 2016 Immediate dental implant placement into infected vs noninfected sockets: a meta-analysis
Number of Included Studies
16b
Is very difficult to state categorically that the placement of an immediate implant in sockets associated to endoperiodontal infection can be considered as a reliable treatment, considering the little literature available about this topic.
3 (All in humans)
Based on the limited evidence available, the placement of an immediate implant in infected sites has successes rates and clinical outcomes comparable with other modalities of implant treatment.
28 (21 in humans and 7 in animals)
High success rates and normal changes in the bone level support the hypothesis that an immediate implant could be successfully osseointegrated even in the presence of endodontic or periodontal lesions if adequate clinical procedures are performed previously to implant placement
7 (All in humans)
Immediate implant placement into infected sites might increase the failure risk of the implant, compared with an implant placed into a healthy site.
a
Methodological quality of studies was determined through assessment with AMSTAR. bThis study used systematic reviews in humans and animals; however, specific quantity of studies in humans and animals was not clearly reported. AMSTAR, A Measurement Tool to Assess Systematic Reviews.
report. According to Sequeira-Byron et al,19 an important difference exists between the methodology driving a review and how well it was reported.19 A review may have followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement,20 a 27-item checklist which helps authors to improve the quality of the report of their SRs and meta-analysis, and yet not have high methodological quality, such as the studies of Lee et al,17 Chrcanovic et al,16 and Zhao et al.18 In the study by Zhao et al,18 which had the highest methodological quality score (8 of 11 according to
THE JOURNAL OF PROSTHETIC DENTISTRY
AMSTAR), the authors reported the values of implant failure rate in percentage. However, we inserted in Table 2 the minimum and maximum values for the implant survival rate. The authors of this study were consulted by e-mail and acknowledged the existence of typographical errors in Table 1 of their study (Characteristics of studies included in meta-analysis) and that the term “Failure Rate” in that table should be replaced by “Survival Rate” (of the implant). The main conclusion of this meta-analysis, which differs from the conclusions of the other 4 SRs regarding the focus theme (Table 3), was
de Oliveira-Neto et al
-
2016
supported by a risk ratio (RR) of 2.16 (95% confidence limits: 0.97, 4.80) and without statistical significance (P=.058). This RR was calculated for the immediate placement of dental implants into infected sockets compared with the immediate placement of dental implants into noninfected sockets. All studies included in the present overview, except for Waasdorp et al14 and Álvarez-Camino et al,15 had as secondary outcomes the recession of the alveolar crest. Considering values reported in Table 2, one can observe that such values of recession are minimum, with the maximum value of the range of 2 studies17,18 below 1 mm. Only in the study by Chrcanovic et al16 was the maximum range value close to 2 mm. The same maximum values reported by the authors regarding the immediate placement of dental implants into infected sites are insignificant from the clinical point of view, and this minimum recession could have occurred as a consequence of the surgical protocol chosen to install the implant. Zhao et al18 performed meta-analysis for the aforementioned outcome (the recession of the alveolar crest), which did not show statistical significance (P=.17; 95% confidence interval). The present overview is important for clinical practice because none of the included studies had high methodological quality and these studies could be used to formulate and establish important surgical decisions, which could lead to loss of time, increased costs and, especially, adverse effects on the patient’s health regarding the immediate placement of dental implants into infected sites. The reasons for dental implant failure reported in the studies need to be considered. Considering the causes of retrograde periimplantitis,21 did the surgeon follow the protocols for alveolar disinfection before the immediate implant placement, and were patient-related risk factors such as smoking, alcohol use, and diabetes considered? Did the surgeon adequately plan the occlusion of the patient or was the implant placed in premature contact? Were the hygiene habits of the patient considered to prevent periodontal disease and consequently implant instability, which could lead to future implant failure? A great divergence was found among the included studies on the topic “periapical infection.” Future primary studies that assess “periapical infection” should investigate beyond the clinical diagnosis. The quantitative and qualitative microbiological diagnosis must also be known. We suggest that future primary studies perform a microbiological analysis as eligibility criteria in order to avoid confusion regarding the kind of periapical infection present before the immediate implant placement or even whether an infection was actually present. CONCLUSIONS The SRs that assessed the immediate placement of dental implants into infected sites had a methodological quality
de Oliveira-Neto et al
5
assessed as low or moderate. The focused topic remains controversial because the implant survival rate, the main outcome considered for the implant placement prognosis, presents contradictory results and conclusions. REFERENCES 1. Linde K, Willich SN. How objective are systematic reviews? Differences between reviews on complementary medicine. J R Soc Med 2003;96:17-22. 2. Lau J, Ioannidis JPA, Schmid CH. Summing up evidence: one answer is not always enough. Lancet 1998;351:123-7. 3. Gopalakrishnan S, Ganeshkumar P. Systematic reviews and meta-analysis: understanding the best evidence in primary healthcare. J Family Med Prim Care 2013;2:9-14. 4. Shea BJ, Grimshaw JM, Wells GA, Boers M, Andersson N, Hamel C, Porter AC, et al. Development of AMSTAR: a measurement tool to assess the methodological quality of systematic reviews. BMC Med Res Methodol 2007 15;7:10. 5. Barbosa FT, Castro AA, Miranda CT. Anestesia neuroaxial comparada à anestesia geral para procedimentos na metade inferior do corpo: revisão sistemática de revisões sistemáticas. Rev Bras Anestesiol 2012;62:235-43. 6. Shea BJ, Hamel C, Wells GA, Bouter LM, Kristjansson E, Grimshaw J, et al. AMSTAR is a reliable and valid measurement tool to assess the methodological quality of systematic reviews. J Clin Epidemiol 2009;62:1013-20. 7. Shea BJ, Bouter LM, Peterson J, Boers M, Andersson N, et al. External validations of A Measurement Tool to Assess Systematic Reviews (AMSTAR). PLoS One 2007;2:e1350. 8. Oxman AD, Guyatt GH. Validation of an index of the quality of review articles. J Clin Epidemiol 1991;44:1271-8. 9. Sacks H, Berrier J, Reitman D, Ancona-Berk VA, Chalmers TC. Meta-analyses of randomized controlled trials. N Engl J Med 1987;316:450-5. 10. Fugazzotto P. A retrospective analysis of immediately placed implants in 418 sites exhibiting periapical pathology: results and clinical considerations. Int J Oral Maxillofac Implants 2012;27:194-202. 11. Esposito M, Grusovin MG, Polyzos IP, Felice P, Worthington HV. Timing of implant placement after tooth extraction: immediate, immediate-delayed or delayed implants? A Cochrane systematic review. Eur J Oral Implantol 2010;3:189-205. 12. Rosenquist B, Grenthe B. Immediate placement of implants into extraction sockets: Implant survival. Int J Oral Maxillofac Implants 1996;11:205-9. 13. Jofre J, Valenzuela D, Quintana P, Asenjo-Lobos C. Protocol for immediate implant replacement of infected teeth. Implant Dent 2012;21:287-94. 14. Waasdorp JA, Evian CI, Mandracchia M. Immediate placement of implants into infected sites: a systematic review of the literature. J Periodontol 2010;81: 801-8. 15. Álvarez-Camino JC, Valmaseda-Castellón E, Gay-Escoda C. Immediate implants placed in fresh sockets associated to periapical infectious processes. A systematic review. Med Oral Patol Oral Cir Bucal 2013;18:780-5. 16. Chrcanovic BR, Martins MD, Wennerberg A. Immediate placement of implants into infected sites: a systematic review. Clin Implant Dent Relat Des 2015;17(suppl 1):e1-16. 17. Lee CT, Chuang SK, Stoupel J. Survival analysis and other clinical outcomes of immediate implant placement in sites with periapical lesions: systematic review. Int J Oral Maxillofac Implants 2015;30:268-78. 18. Zhao D, Wu Y, Xu C, Zhang F. Immediate dental implant placement into infected vs. non-infected sockets: a meta-analysis. Clin Oral Implants Res 2016;27:1290-6. 19. Sequeira-Byron P, Fedorowicz Z, Jagannath VA, Sharif MO. An AMSTAR assessment of the methodological quality of systematic reviews of oral healthcare interventions published in the Journal of Applied Oral Science (JAOS). J Appl Oral Sci 2011;19:440-7. 20. Moher D, Liberati A, Telzlaff J, Altman DG; , for the PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 2009;6:e1000097. 21. Nguyenhieu T, Borghetti A, Aboudharam G. Peri-implantitis: from diagnosis to therapeutics. J Investig Clin Dent 2012;3:79-94.
Corresponding author: Dr Olavo Barbosa de Oliveira-Neto Faculty of Dentistry Federal University of Alagoas Campus A.C. Simões. Lourival Melo Mota Ave Tabuleiro dos Martins, Maceió, AL 57072-900 BRAZIL Email: [email protected] Copyright © 2016 by the Editorial Council for The Journal of Prosthetic Dentistry.
THE JOURNAL OF PROSTHETIC DENTISTRY