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An integrated approach to dental implantation in patients who underwent Cavid-19
Mannаnov Zhavlonbek Zhamoliddinovich
Assistant of the Department of Surgical Dentistry and dental implantology Tashkent State Dental
institute
Pulatova Barno Zhurakhonovna
Associate Professor at the Department of Oral and Maxillofacial Surgery Tashkent State
Dental Institute, DcS
Nazarov Zafar Ziyodullaevich
Assistant of the Department of Surgical Dentistry and dental implantology Tashkent State
Dental institute
Khasanov Shukhrat Makhmudovich
Head of the Department of Surgical Dentistry and dental implantology Tashkent State
Dental Institute
Khomidov Muhammad Abdusobitovich
Assistant of the Department of Surgical Dentistry and dental implantology Tashkent State
Dental institute
https://doi.org/10.5281/zenodo.7214711
Abstract:
The feasibility and effectiveness of complex treatment in patients with secondary
adentia and past Covid-19 was assessed. The planning of dental implantation in patients who have
undergone Cavid-19 should be carried out with the most complete use of diagnostic procedures,
including clinical, laboratory and functional examination of the patient. A systematic analysis of the
studies conducted at all stages of dental treatment allows us to conclude that there are relative
contraindications to dental implantation in patients with underlying pathology and who have
undergone Cavid-19.
Keywords:
coronavirus pathology Covid-19, dental implantation, hemostasis.
.
Relevance of the problem.
Currently, scientists around the world are paying increased attention to the problem of the
Covid-19 pandemic, the entire population living on planet Earth was exposed to a mild and
moderate coronavirus infection, 58% of the earth's population suffered this infection in a severe
form, 27% with a fatal outcome.
On March 11, 2020, the World Health Organization declared COVID-19 a pandemic.
As of 08/03/2021, there were 199,622,425 cases of confirmed morbidity worldwide
(including 131,978 in Uzbekistan), 4,250,338 deaths (including 886 in Uzbekistan) [1].
The infectious disease COVID-19 is caused by the SARS-CoV-2 virus, which belongs to the
large family of coronaviruses. The virus consists of a single-stranded RNA, an envelope and a lipid
layer. The novel SARS-CoV-2 coronavirus, severe acute respiratory syndrome coronavirus (SARS-
CoV), belongs to the same genus of betacoronaviruses [10,11].
Ways of transmission of Covid-19 from person to person: airborne - when sneezing or
coughing, contact - directly from an infected person, through infected surfaces. The entrance gates
for the virus to enter the div are the mucous membranes of the nose, mouth and eyes.
The results of the research, consisting in the fact that the ACE2 enzyme is expressed in the
mucous membrane of the oral cavity, and to be more precise, in the epithelium of the tongue. In this
regard, the main mechanism has been elucidated, according to which the oral cavity represents a
potentially high risk of infectious susceptibility to 2019-nCoV [8].
Excessive activation of systemic immunity after infection with SARS-CoV-2 causes the so-
called "cytokine storm", in which released cytokines - tumor necrosis factors (TNF), interleukin-6
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(IL-6) and interleukin-1β (IL-1β) - damage div cells. This can lead to increased vascular
permeability, and subsequent damage to organs such as the kidneys and heart, leading to multiple
organ failure and death [10,12,13].
In case of circulatory disorders caused by the development of an infectious and
inflammatory process, the most vulnerable elements of the microvascular system are primarily
affected: arterioles, precapillary arterioles, blood capillaries, postcapillary venules and venules.
In the pathogenesis, clinical manifestations and course of many diseases of the oral cavity,
disorders at the microhemocirculatory level are the leading link.
To date, dental implantology is a fundamentally sound approach to the treatment of adentia,
which contributes to an increase in the clinical effectiveness of this complex of minimally invasive
methods and their widespread introduction into the practice of modern dentistry [Losev F.F., 2010;
Mirgazizov M.Z., 1999; Nikitin A.A., 2010; Olesova V.N., 2009, 2010; Robustova T.G., 2003].
However, to date, in domestic dentistry, there are practically no reports on the results of
complex clinical and experimental studies in patients with a history of coronavirus infection and
devoted to a comparative assessment of the clinical and economic efficiency of using microsurgical
methods during dental implantation in patients with partial and complete secondary adentia.
The implantation procedure in patients with somatic pathology, especially infectious-viral
etiology, can itself provoke an exacerbation of those diseases that the patient suffers from.
From the point of view of an implantologist, it is important that with prolonged arterial
hypertension, reduced immunity due to Covid-19, and regular use of antihypertensive, anticoagulant
drugs, the phenomenon of "rarefaction" or "discharge" occurs, which is expressed in a reduction in
the total surface of the exchange vessels [Jablonski D, 2004].
The presence of concomitant somatic pathology in patients with a coronavirus infection of
viral etiology who need dental implantation indicates the relevance of this problem, on the one
hand, and its practical significance, on the other hand.
Purpose of research:
Improve treatment through an integrated approach in the use of dental implantation in
patients who have had a coronavirus infection in preparation for prosthetics.
Materials and methods of research.
49 patients were under observation when applying for treatment for the purpose of
implantation and further prosthetics were diagnosed in the anamnesis of a coronavirus infection.
Treatment of patients with this pathology was carried out in the period from 2020 to December
2021 at the clinic of the Department of Surgical Dentistry and Dental Implantation of the Tashkent
State Dental Institute. Among the patients, men predominated - 26 (53%). Of the examined patients,
20 people received the complex treatment developed by us. A comparison was made with patients
receiving traditional treatment - 11 people, with patients without pathology of periodontal tissues -
20 people. Patients in the groups were comparable in age, gender, type of bone tissue and the depth
of periodontal tissue damage. The control group included 17 practically healthy people.
The distribution according to the severity of the inflammatory process in periodontal tissues
was as follows: patients with gingivitis - 16 people, mild periodontitis - 23 people, moderate - 5
people and severe - 5 people. The age of the examined patients ranged from 21 to 54 years (mean
age 31.4±8.2 years).
Clinical Research Methods
The program for examining patients was standardized and included the identification of
complaints, the collection of anamneses, the assessment and analysis of the dynamics of clinical
manifestations aimed at objectifying the disease, the course of the wound process, and determining
the effectiveness of treatment. Additionally, a laboratory blood test, urine test was performed.
When assessing the local status, attention was paid to the degree of immune defense of the
div, the structure of bone tissue in the area of the planned operation, and the degree of periodontal
damage.
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Carried out laser Doppler flowmetry using a laser analyzer of capillary blood flow - LAKK-
01, coupled with a personal computer. This is a method for the non-invasive determination of tissue
perfusion with blood by measuring the Doppler frequency shift that occurs when laser radiation is
probed by red blood cells moving in the microvasculature. A light guide probe made of three
monofilaments was used as the analyzer sensor.
To clarify the state of the bone structure of the area of the upcoming implantation, 3D
Computed radiography of the jaws was performed.
Assessment of the hemostasis system and rheological properties of blood
As special research methods, indicators of the antithrombogenic activity of the vascular wall
and the rheological properties of blood were used.
To determine the antithrombogenic properties of the endothelium of the vascular wall
(antiaggregation, anticoagulant and fibrinolytic activity), a method is used based on the creation of a
short-term (5 min.) Local ischemia caused by applying a sphygmomanometer cuff to the subject's
shoulder and creating a pressure in it that exceeds the systolic pressure by 10 mm Hg. Art., which
leads to the release of prostacyclin, nitric oxide, endothelins, antithrombin III, tissue plasminogen
activators from the vascular endothelium of healthy people into the blood. Determination of the
content or activity of hemocoagulation factors in the blood taken before and after a short-term
occlusion of the vessels, makes it possible to judge the state of the antithrombogenic activity of the
vessel wall (Baluda V.P. et al., 1992).
Studies in patients who were at rest were carried out in the morning, on an empty stomach.
A tourniquet was applied to the shoulder of one arm, the cubital vein was punctured with a
siliconized needle, and blood was taken by gravity into a non-wetted plastic tube up to the 10 ml
mark. A 3.8% solution of sodium citrate in a ratio of 9: 1 was used as a stabilizer.
A sphygmomanometer cuff was applied to the second arm, systolic pressure was
determined, and the pressure in the cuff was increased by 10 mmHg. and after 5 minutes, 9 ml of
blood was taken into a test tube containing 1 ml of 3.8% sodium citrate solution.
Both tubes were centrifuged for 10 minutes at 1000 rpm to obtain PRP.
We determined platelet aggregation before and after the creation of short-term ischemia of
the upper limb by the method proposed in 1989 by Z.A. Gabbasov et al., using a laser aggregation
analyzer "BIOLA" 230 Ltd (Russia), interfaced with an IBM-compatible computer and a
specialized MS Windows - compatible program "Aggr" (SPF "Biola").
Based on the determination of the maximum degree of platelet aggregation in plasma
obtained before the cuff test, the aggregation ability of the patient's platelets was judged. Based on
the results of determining the maximum degree of platelet aggregation in plasma obtained before
and after the cuff test, and calculating the index of antiaggregation activity, the antiaggregation
activity of the endothelium of the vascular wall was judged. The total antiaggregatory activity of the
vessel wall was expressed by an index equal to the quotient of dividing the indicator of the
maximum degree of platelet aggregation before cuffing by the indicator of the maximum degree of
platelet aggregation after cuffing.
An open method of dental implants was used (with simultaneous installation of gingival
edge shapers)
When examining patients at the preoperative stage, we used general clinical (taking an
anamnesis, examining the site of the proposed implantation, measuring blood pressure and pulse),
radiological (aimed radiography, panoramic sonography (orthopantomography) and computed
tomography), functional and laboratory methods of examination (laser Doppler flowmetry, ECG,
periotestometry, biochemical blood test)
To assess the quality of the bone, we used the classification of bone density Misch and Judy,
1987, in comparison with the data of the X-ray scale for assessing tissue density, expressed in
Hounsfield units
To confirm the diagnosis of Cavid-19 in history, PCR studies and testing for the presence of
antibodies to SARS-CoV-2 coronavirus infection IgMScreen (Covid-19) were carried out
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Statistical processing of the obtained data was carried out using variational statistics, the
arithmetic mean value was calculated, the degrees of freedom of the arithmetic mean value. The
significance of differences between the mean values of the study groups and control groups was
determined by Student's t-test.
Research results and discussion
.
All patients had partial absence of teeth, where the last extraction was carried out at least 6
months ago. After the completion of the procedure for installing dental implants, clinical
observation of patients was carried out, which included the following steps: clinical assessment of
the effectiveness of the functioning of the orthopedic crown and the condition of the periodontal
tissues near the implants; measurement of their stability by resonance frequency analysis (RFA)
using the Osstell ISQ apparatus (Osstell AB, Sweden).
In the immediate postoperative period, when examining the patient, his general condition
after intraosseous implantation was also assessed according to the following criteria: the presence of
complaints, including pain in the area of the operation; Body temperature; the presence of
hematoma and swelling of the face;
The condition of the submandibular and cervical lymph nodes; the degree and nature of
changes in the mucous membrane of the alveolar process in the area of operation; discomfort and
pain during the act of chewing in cases of immediate loading of the implant.
Photographing of the patient and the implantation site was carried out immediately at the
time of implantation, 7–10 days, 1,2,3,4,5, 6 months after implantation in the upper jaw and 7–10
days, 1,2,3 months after implantation on the lower jaw (Fig. 1 and Fig. 2).
Fig.1 a - upper jaw before treatment; b-moment of implant installation
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Fig. 2 a - the implants are immersed in the implantation bed; b-checking the parallelism of the
installed implants.
LDF-metry of patients was performed in a dental chair, in a sitting position before the start of
treatment and 1 month after the proposed drug treatment.
Table 1. Indicators of LDF signal amplitudes before treatment
Indicators
M,
perf. units
,
perf. units
Kv,%
Control group
26,51 ± 1,88
2,60 ± 0,40
12,44 ± 0,80
I group
32,57 ± 1,98
1,85 ± 0,16
6,60 ± 1,05
II group
32,29 ± 0,67*
2,98 ± 0,77*
6,93 ± 1,43
Fig.3 a-patient with atrophied lower jaw; b-separation of the mucous membrane
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а) б)
Fig. 4 a-Implants were installed in the alveolar process of the lower jaw;
b-mucous membrane sutured with polyamide thread
In the group of individuals with complete secondary adentia of the upper jaw, the LDF-gram
made it possible to identify the normative parameters of microcirculation in the oral mucosa (Table
1). Thus, in the group of healthy individuals, the value of capillary blood flow in terms of the
microcirculation parameter (PM) was 26.51 ± 1.88 perf. units The mean square deviation of blood
flow fluctuations (RMS) was 2.60 ± 0.40 perf. units, and the coefficient of variation (Kv) was 12.44
± 0.80%.
From table 1 it follows that the values of the LDF-gram are increased in the group with the
most pronounced inflammatory reaction of the oral mucosa compared to the control group. This is
evidenced by an increase in the index of microcirculation in group II by 48-53%, which reflects
stagnation in the study area. A pronounced decrease in the level of such indicators as "flux" and the
coefficient of variation indicates violations of the rhythmic structure of tissue blood flow
oscillations, which is associated with a deterioration in tissue perfusion with blood.
In the second group of patients, with severe periodontitis, before the start of treatment, when
studying the capillary blood flow of the mucous membrane, pronounced microcirculatory disorders
were noted: the microcirculation index was 32.57 ± 1.98, SD - 1.85 ± 0.16; the coefficient of
variation was 6.60 ± 1.05%, at which a complex of changes occurs, associated with a sharp
difficulty in the outflow of blood, disturbances in the structure of microvessels and the barrier
function of their walls. When studying the statistical analysis of the data obtained using LDF-metry,
we did not reveal significant differences between groups I and II (p > 0.05). In the first group of
patients, we obtained the following average values of capillary blood flow: PM — 32.29 ± 0.67; SD
— 2.98 ± 0.77; Kv - 6.93 ± 1.43%. The data obtained show that the blood flow intensity of both
comparison groups differ significantly from the values of the control group (table).
Table 2. Indicators of LDF signal amplitudes one month after the start of treatment.
Indicators
М,
perf. units
,
perf. units
Kv,%
Control group
29,57 ± 1,38
2,80 ± 0,46
14,41 ± 0,35
I group
31,97 ± 1,65
2,15 ± 0,11
6,58± 1,43
II group
34,50 ± 0,13*
3,01 ± 0,14*
8,98 ± 1,62
Statistical analysis of LDF-metry data after a month in patients showed the following values
(Table 2).
When examining a month later in patients of the group without additional treatment, the
arithmetic mean values of the PM index in the study area of the tissues of the prosthetic bed were
31.97 ± 1.65 perf. units, - 2.15 ± 0.11 perf.un. and Kv - 6.58 ± 1.43%. In the group of patients
who were prescribed, in addition to the complex treatment, the drug "thyrocalcitonin" (Fig. 3 and
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Fig. 4), the average values of the LDF-metry parameters were: PM - 34.50 ± 0.13; SD — 3.01 ±
0.14; Kv - 8.98 ± 1.62%
Insignificant changes in LDF-metry parameters were noted in the group of the most
pronounced inflammatory changes in the mucous membrane and without additional treatment,
compared with the control group. This is evidenced by PM: there is a slight increase in the level of
the LDF signal on the mucosa of the prosthetic bed. An increase in the RMS by only 7.4%
compared with the previous study indicates a low elasticity of the vascular wall, an increase in the
inflow of arterial blood into the microcirculatory bed, reduced microcirculatory pressure,
deterioration of blood outflow, and residual manifestations of blood stagnation in the
microcirculatory bed.
The constant values of the coefficient of variation indicate a decrease in the elasticity of the
vascular wall, impaired outflow in the microcirculatory bed, as a result, an increase in blood volume
in the microcirculatory link, which indicates the presence of congestion in the oral cavity. It should
be noted that during this period of time there were no exacerbations of the disease, the LDF-gram
was performed on the unchanged oral mucosa, and not in the lesion.
A statistically significant difference between the values of the coefficient of variation in
group II, in relation to group I, indicates an improvement in the state of microcirculation in patients
who, in addition to local treatment, received the drug thyrocalcitonin. In this group, the coefficient
of variation increased by 1.3 times compared with the initial values, which indicates a decrease in
congestion in the oral cavity, which indicates the launch of compensatory-adaptive mechanisms in
group II. Perhaps this is due to the ability of calcitonin, which is involved in the regulation of
phosphorus-calcium metabolism in the div, as well as the balance of osteoclast and osteoblast
activity. A statistically significant difference in Kv values indicates more pronounced inflammatory
manifestations in patients who did not take any additional treatment.
Thus, the use of LDF-metry in patients with secondary edentulous jaws on the background
of Covid-19 disease makes it possible to optimize existing pathogenetic therapy regimens based on
various combinations of drugs. Laser Doppler flowmetry can be used both to monitor the state of
microcirculation and to control drug exposure.
Measurement of stability by resonance frequency analysis (RFA) using the Osstell ISQ
apparatus was carried out in groups 1 and 2 - immediately at the time of implantation, 6 months
after implantation in the upper jaw and 3 months after implantation in the lower jaw.
X-ray assessment of the degree of osseointegration of the dental implant and the state of the
jaw bone tissue near it was performed during the following time intervals: 3 months and 6 months
after implantation.
Fig. 5 Computer study of a patient with a history of secondary edentulism with Covid-19.
postoperative monitoring.
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As a rule, to assess the state of the tissues of the bone-implant interface, targeted
radiography in the area of installed implants and a standard orthopantomographic study were used.
Fig.6 Computed tomography before implant placement
Computed tomography was performed before the installation of implants (Fig. 6) a week
after the surgical stage of implantation, after the installation of prostheses, 6 months after
prosthetics, then, in the absence of complaints from the patient, with an interval of one year.
Fig.7 One week after the surgical stage of implantation,
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Fig. 8. 3 months after surgery.
Six months after the start of the full functioning of the implants, the X-ray study also did not
show any visible bone resorption, both in the control group and in the studied ones.
A week after the manipulation, in patients of the control group, as a rule, there was a slight
horizontal resorption in the area of the necks of the installed implants.
Two years later, after the surgical stage of dental implantation, some patients of the control
group (40%) have horizontal bone resorption in the area of the bone-implant interface. Its average
value is approximately 0.8 ± 0.2 mm.
It should be noted that the presence of horizontal resorption of the bone tissue of the bone-
implant interface with a depth of no more than 1.5 mm at a period of 2 years from the moment of
implant placement is normal and does not have any negative prognostic impact.
Conclusions.
1. Based on the results of modern diagnostic methods, a comprehensive approach has been
developed for dental implantation in patients with a history of Covid-19, which allows assessing the
local status of mucosal tissues in the area of planned intervention.
2. When planning the implantation operation, evidence was obtained of a slowdown in the
blood flow of the microvasculature in the tissues of the area of the proposed intervention, which
undoubtedly has a negative impact on the process of osseointegration.
3. For patients who received the drug "thyrocalcitonin" during the interventions, the
coefficient of variation increased by 1.3 times compared with the initial values, which indicates an
improvement in the state of microcirculation, as well as a decrease in congestion in the oral cavity,
which indicates the launch compensatory-adaptive mechanisms in group II.
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