Nonsurgical Modalities Research Articles

Delphi Consensus Among International Experts on the Diagnosis, Management, and Surveillance for Lentigo Maligna.

Melanoma of the lentigo maligna (LM) type is challenging. There is lack of consensus on the optimal diagnosis, treatment, and follow-up. To obtain general consensus on the diagnosis, treatment, and follow-up for LM. A modified Delphi method was used. The invited participants were either members of the International Dermoscopy Society, academic experts, or authors of published articles relating to skin cancer and melanoma. Participants were required to respond across three rounds using a 4-point Likert scale). Consensus was defined as >75% of participants agreeing/strongly agreeing or disagreeing/strongly disagreeing. Of the 31 experts invited to participate in this Delphi study, 29 participants completed Round 1 (89.9% response rate), 25/31 completed Round 2 (77.5% response rate), and 25/31 completed Round 3 (77.5% response rate). Experts agreed that LM diagnosis should be based on a clinical and dermatoscopic approach (92%) followed by a biopsy. The most appropriate primary treatment of LM was deemed to be margin-controlled surgery (83.3%), although non-surgical modalities, especially imiquimod, were commonly used either as alternative off-label primary treatment in selected patients or as adjuvant therapy following surgery; 62% participants responded life-long clinical follow-up was needed for LM. Clinical and histological diagnosis of LM is challenging and should be based on macroscopic, dermatoscopic, and RCM examination followed by a biopsy. Different treatment modalities and follow-up should be carefully discussed with the patient.

Bromelain-based enzymatic burn debridement: A systematic review of clinical studies on patient safety, efficacy and long-term outcomes.

In 2012 the European Medicines Agency approved a pineapple stem-derived Bromelain-based debridement concentrate of proteolytic enzymes (NexoBrid®, MediWound Ltd, Yavne, Israel) for adult deep burns. Over 10 000 patients have been successfully treated with NexoBrid® globally, including in the US. The aim of our study is to perform a systematic review of the current literature on Nexobrid® outcomes. We conducted a literature search in PubMed, Google Scholar, Embase, and other search engines (2013-2023). The online screening process was performed by two independent reviewers with the Covidence tool. The protocol was reported using the Preferred Reporting Items for Systematic Review and Meta-Analyses, and it was registered at the International Prospective Register of Systematic Reviews of the National Institute for Health Research. We identified 103 relevant studies of which 34 were found eligible. The included studies report the positive effects of Nexobrid® on burn debridement, functional and cosmetic outcomes, scarring, and quality of life. Also, they validate the high patient satisfaction thanks to enhanced protocols of analgosedation and/or locoregional anaesthesia during Bromelain-based debridement. Two studies investigate potential risks (coagulopathy, burn wound infection) which concluded there is no strong evidence of these adverse events. NexoBrid® is a safe, selective, non-surgical eschar removal treatment modality. The benefits of Bromelain-based debridement are faster debridement and healing times, reduced operations, length of stay, cases of sepsis, blood transfusions, and prevention of compartment syndrome. Existing evidence suggests that the indications and the role of Bromelain-based debridement are expanding to cover "off-label" cases with significant benefits to the global healthcare economy.

Transarterial chemoembolization for hepatocellular carcinoma: 2023 expert consensus-based practical recommendations of the Korean Liver Cancer Association.

Transarterial chemoembolization (TACE) was introduced in 1977 with the administration of chemotherapeutic agent to gelatin sponge particles through the hepatic artery in patients with hepatocellular carcinoma (HCC) and was established as conventional TACE using Lipiodol in the 1980s. In the 2000s, drug-eluting beads were developed and applied clinically. Currently, TACE is a commonly used non-surgical treatment modality for patients with HCC who are unsuitable for curative treatment. Considering the vital role of TACE in the management of HCC, it is crucial to organize current knowledge and expert opinions regarding patient preparation, procedural techniques, and post-treatment care in TACE, which can enhance therapeutic efficacy and safety. A group of 12 experts in the fields of interventional radiology and hepatology, convened by the Research Committee of the Korean Liver Cancer Association (KLCA), has developed expert consensus-based practical recommendations in TACE. These recommendations have been endorsed by the Korean Society of Interventional Radiology and provide useful information and direction in performing TACE procedure as well as pre- and post- procedural patient care.

Stem Cell Therapy in Critical Limb Ischemia.

Critical limb ischemia (CLI), a serious outcome of peripheral artery disease, is frequently associated with morbid outcomes. The available treatment modalities do not provide satisfactory results, leading to marked morbidities such as joint contracture and amputations, resulting in a high economic burden. The peripheral vascular disease tends to cause more morbidity in patients with diabetes and atherosclerosis, given the pre-existing compromised perfusion of medium and small vessels in diabetic patients. With surgical procedures, the chance of vascular compromise further increases, inducing a significantly greater rate of amputation. Hence, the need for nonsurgical treatment modalities such as stem cell therapy (SCT), which promotes angiogenesis, is warranted. In CLI, SCT acts through neovascularization and the development of collateral arteries, which increases blood supply to the soft tissues of the ischemic limb, providing satisfactory outcomes. An electronic database search was performed in PubMed, SCOPUS, EMBASE, and ScienceDirect to identify published clinical trial data, research studies, and review articles on stem cell therapy in critical limb ischemia. The search resulted in a total of 2391 results. Duplicate articles screening resulted in 565 articles. In-depth screening of abstracts and research titles excluded 520 articles, yielding 45 articles suitable for full-text review. On review of full text, articles with overlapping and similar results were filtered, ending in 25 articles. SCT promotes arteriogenesis, and bone marrow-derived mesenchymal stromal cells produce significant effects like reduced morbidity, improved amputation-free survival (AFS ) rate, and improved distal perfusion even in "no-option" CLI patients. SCT is a promising treatment modality for CLI patients, even in those in whom endovascular and revascularization procedures are impossible. SCT assures a prolonged AFS rate, improved distal perfusion, improved walking distances, reduced amputation rates, and increased survival ratio, and is well-tolerated.

Effect of Microneedling and Injectable Platelet-Rich Fibrin on Gingival Phenotype – A Case Series

Introduction: Gingival phenotype is a crucial determinant of the periodontium. It not only maintains the health of the tissue but also plays a decisive role in the prediction of periodontal treatment outcomes. Thin gingival phenotype poses certain risks of poor periodontal treatment outcome in cases of implant, coronally advanced flap, and other root coverage procedures. Thus it becomes the duty of the clinician to deal with such cases by prior planning treatments which can improve the gingival phenotype and thereby enhancing the postperiodontal treatment outcomes to benefit patients. In this case series, a nonsurgical treatment modality microneedling (MN) and injectable platelet-rich fibrin (i-PRF) are employed in an attempt to increase the thickness of thin gingival phenotype. Methods: Five systemically healthy patients with thin gingival phenotypes were included in this study. The lower anterior teeth with split-mouth study pattern have been randomly allocated to nonsurgical treatment modality, i.e., MN alone and MN along with i-PRF. All the patients were followed up for 9 months. Outcomes Assessed: Gingival thickness (GT), Width of Keratinized Tissue (WKT), oral hygiene index, gingival index (GI), the patient reported outcome measures. Results: Both the groups showed an increase in the thickness of gingiva in 9-month follow-up. The mean increase of 0.62 mm in thickness was seen in Group 1 (42%), whereas Group 2 showed a 0.34 mm (27.3%) of increment. No difference is seen with respect to the change in the width of keratinized gingiva in both groups. Conclusion: MN along with i-PRF can provide an efficient nonsurgical option to clinicians to increase GT in cases of thin gingival phenotype.

Case series: Noninfectious myositis of temporal muscle: a report of 2 cases.

Noninfectious myositis (NIM) of the masticatory muscles is uncommon local myalgia disorder persisted by a centrally-mediated neurogenic mechanism. Due to the rarity of this condition and the lack of appropriate data regarding it, diagnosing this pathology when it affects the temporal muscle (TM) is challenging. Clinical signs and symptoms, diagnostic process, and treatment outcome of 2 rare cases of NIM of the TM were presented. The signs and symptoms of the patients were not pathognomonic. There were restrictions on the mouth opening and lateral excursion of the mandible. The duration of the symptoms may not be chronic. The findings of clinical evaluation may indicate the diagnosis of anterior disc displacement (DD) without reduction of the temporomandibular joint (TMJ) and/or local myalgia. Swelling of the involved muscle could be evident and identified on palpation depending on the involved site of myositis. The axial T2-weighted magnetic resonance (MR) imaging was important for the accurate diagnosis of this rare condition. Application of non-surgical conservative treatment modalities such as administration of non-steroidal anti-inflammatory analgesics for a sufficient period of time, control of oral parafunctional habits, and jaw exercises were effective for the management of NIM of the TM. A thorough clinical examination and MR imaging including the axial T2-weighted view are required for accurate diagnosis and effective management of NIM of the TM.

Comparison of full-mouth and partial-mouth disinfection modalities in nonsurgical periodontal treatment for periodontitis: a randomized clinical trial in vietnam

Background: Periodontitis is the most common form of periodontal disease, greatly affecting the aesthetics, function as well as patient’s quality of life. In the periodontal disease treatment strategy, nonsurgical treatment is considered as the initial phase for anti-infection and soft-tissue management. Objective: This study aims to compare the effect of two nonsurgical periodontal modalities: one-stage full-mouth and partial-mouth protocols for periodontitis. Materials and Methods: 60 patients with chronic periodontitis were randomly allocated to 2 groups. Group I (n = 30) was treated according to partial-mouth therapy. Group II (n = 30) was treated according to full-mouth disinfection therapy. Periodontal parameters were assessed at baseline and 1, 3, and 6 months, including plaque index, gingival index, periodontal probing depth, clinical attachment loss, and bleeding on probing. Results: Both two treatment modalities resulted in significant improvements in all clinical parameters over the entire duration of the study (p < 0.05). Full-mouth disinfection therapy showed significantly better improvements than the partial-mouth one during follow-up times (p < 0.05). Conclusion: Nonsurgical periodontal treatment has positive effects on controlling periodontitis. Full-mouth therapy shows clinical benefits over partial-mouth therapy in improving periodontal conditions. Key words: Periodontitis, nonsurgical periodontal therapy, full-mouth therapy, partial-mouth therapy.

Surgery vs. radiotherapy in a population-based cohort of elderly patients with early-stage small-cell lung cancer: an IPTW propensity-score analysis.

Due to the lack of treatment outcome data comparing surgical and non-surgical treatment modalities in the era of contemporary staging and treatments, the management of elderly patients with early-stage small cell lung cancer (SCLC) continues to be debated. This study sought to compare surgery and radiotherapy in elderly patients (aged ≥70 years) with early-stage SCLC using data from the Surveillance, Epidemiology, and End Results (SEER) database. The inverse probability of treatment weighting (IPTW) method was used to address the selection bias between the surgery and radiotherapy groups. The Kaplan-Meier method and multivariate Cox proportional hazards regression were used to compare the overall survival (OS) of the treatment cohorts before and after the IPTW adjustment. The competing risk survival analyses used Fine and Gray's method to compare the cancer-specific survival between the groups. Between 2004 and 2018, 685 elderly patients received local treatment for early-stage SCLC. Of these patients, 193 patients (26.6%) received surgery and 492 patients (73.4%) received radiotherapy. Surgery was associated with a longer OS time than radiotherapy (median OS time: 32 vs. 20 months; 5-year OS time: 30.6% vs. 17.6%; P=0.002). The survival advantage of surgery was consistent in the IPTW-adjusted cohort (median OS time: 32 vs. 20 months; 5-year OS time: 30.6% vs. 17.6%; P<0.002). In the multivariate analysis, an increased age (P=0.001), stage T2 (P=0.047), radiotherapy (P<0.001), and no chemotherapy (P=0.034) were associated with unfavorable OS. In the IPTW-adjusted cohort, the multivariate analysis showed a decreased age (P<0.001), stage T1 (P=0.038), and surgery (P<0.001) were associated with superior OS. The competing risk analyses demonstrated that surgery produced a consistent decrease in the cancer-specific mortality rate compared to radiotherapy among the patients aged 70-80 years (53.6% vs. 61.0%, P=0.01), but no difference was observed in the 5-year cumulative incidence rate of cancer-related death between the surgery and radiotherapy groups (66.3% vs. 64.9%; P=0.66) in patients aged ≥80 years. In this population-based study of the optimal local treatment for elderly early-stage SCLC, patients who underwent surgery had superior OS compared to those who underwent radiotherapy.

NATURAL HISTORY OF GRADE ONE LUMBOSACRAL ISTHMIC SPONDYLOLISTHESIS IN ADOLESCENT PATIENTS: LONG TERM FOLLOW-UP OF 299 PATIENTS TREATED CONSERVATIVELY

Purpose of the Study: The aim is to report the natural history, type of treatment received and quality of life improvement of adolescent patients with isthmic low-grade lumbosacral spondylolisthesis with a slip of less than 25%. Methods: The complete records of 299 prospective patients (127 males and 172 females) with isthmic low-grade lumbosacral spondylolisthesis referred to an orthopedic clinic were reviewed. Radiological parameters, Micheli scale, and quality of life measured by the SRS-22 questionnaire were measured at the first visit and a minimum 5-year follow-up. Results: The average follow-up time is 5.7 ± 1.4 years. The main complaint at the initial presentation was lower back pain in 107 patients, and three patients had lower back pain and lower limbs radiculopathy. Scoliosis was found in 38 patients in the initial radiograph. One-hundred-eighty-nine patients (63%) were asymptomatic at the time of presentation. At the last follow-up; SRS-22 were 4.21 ± 0.6, 4.21 ± 0.7, 4.31 ± 0.5, 4.21 ± 0.7, 4.2 ± 0.7 for total, pain, function, mental, and self-image scores, respectively. The patients with grade one lumbosacral spondylolisthesis with normal morphology of the sacrum had responded well to the nonsurgical treatment modalities. No patient has progressed during the follow-up, and no patient underwent surgical intervention for back pain. The slip percent was relatively lower in patients with low back pain. The average slip percentage was 15.5 ± 8.4 among the asymptomatic patients and 13 ± 9 among patients who presented with low back pain ([Formula: see text]-value = 0.009). Conclusion: Adolescent patients with grade one isthmic lumbosacral spondylolisthesis have very good prognosis with nonoperative modalities and they have an almost normal quality of life at the end of follow-up. A long follow-up in an outpatient clinic with X-Rays series might not be indicated for all patients with low-grade spondylolisthesis, specifically if the slip is less than 25%.

Phase I therapy in periodontics and periodontal regeneration: Gate to success in dentistry- A review

Periodontal disease is a multifactorial inflammatory condition comprising of a complex interaction between pathogenic bacteria, environmental and acquired factors and host related factors. It is well known that to achieve successful result one must focus on eliminating the cause of disease. In this review we will be discussing most important phase in dental treatment i.e Phase I therapy because the basis of any dental problem ever seen is primarily or secondarily due To “Plaque” Hence Pahse-I Therapy.Scaling and root planning (SRP) is a conventional, non-invasive periodontal therapy and when used alone or as adjunct with other non-surgical therapeutic modalities have shown a great success in dental procedures.

Primary malignant melanoma of the vagina: A case report and a mini review

Primary vaginal melanoma is a rare and aggressive entity affecting the vaginal wall without any involvement of the uterine cervix or the vulva. It usually occurs in elderly women. We hereby present an 87-year-old woman who presented with recurrent vaginal bleeding. Vaginal examination revealed a 3cm hyperpigmented lesion on the anterior vaginal wall. The lesion was biopsied and the results of the histopathological examination were compatible with primary malignant vaginal melanoma. The diagnosis of vaginal melanoma is usually established by histology and immunochemistry. The therapeutic management includes surgical and nonsurgical modalities. Although surgery combined with adjuvant radiotherapy or chemotherapy are acceptable therapeutic approaches, further studies are needed in order to assess the optimal management of women with primary vaginal melanoma.

Clinical and Radiographic Evaluation of Locally Delivered Plant Stem Cells for Treatment of Periodontitis: Randomized Clinical Trial.

Periodontitis causes the destruction of soft and hard tissues. Stem cells have immense potential in regenerative cellular therapy. This clinical trial aimed to evaluate clinically and radiographically the effectiveness of the local application of Edelweiss stem cells as a nonsurgical treatment for stage III periodontitis. The trial included 40 periodontal pockets in participants who have stage III periodontitis with probing pocket depth (PPD) ≥5 mm and clinical attachment loss (CAL) ≥5 mm. Pockets were randomly divided into two groups Group 1: was given oral hygiene instruction, scaling, root planing, and subgingival application of plant stem cells on gel foam carrier after that a periodontal dressing was applied. The procedures were repeated after 2 weeks. Group 2: was treated only by scaling and root planing. Gingival index, CAL, and PPD were measured at baseline and 3 months' posttherapy. The radiographical evaluation was done by digital long-cone parallel periapical radiographs at baseline and 6 months posttherapy. Clinical parameters for both groups showed a statistically significant improvement. Regarding radiographic evaluation, there was a significant increase in bone density in favor of the study group. Locally applied Edelweiss stem cells can be considered a promising nonsurgical treatment modality for periodontal regeneration.

A GLIMMER OF HOPE, THE NON-SURGICAL WAND FOR THE AESTHETIC CORRECTION OF BLACK TRIANGLES - A CASE SERIES

Gingival black triangles present as un-aesthetic embrasure spaces associated with papillary deficiency. With the psycho-social impact of the compromised aesthetics and the desire for appealing smile profile its management becomes the need of the hour. The Non-surgical treatment modalities of the papillary fill were evaluated owing to the scepticism of the patients towards the invasive surgical options for the aesthetic correction owing to associated co-morbidities and time constrains. The Hyaluronic acid fillers emerged as the most efficient and viable option. However, i-PRF demonstrated potential as a promising autologous and cost efficient alternate.

Endoscopic Ultrasound-guided Trans-esophageal Transmural Drainage of Mediastinal Pseudocysts: A Case Series

Mediastinal pseudocysts (MP) are rare, and surgery is the conventional treatment modality. However, in the last decade, excellent outcomes have been reported with endoscopic transpapillary drainage. Endoscopic ultrasound (EUS) guided trans-esophageal transmural drainage of MP is a minimally invasive and effective non-surgical treatment modality, but the experience is limited. We aimed to report our experience of EUS-guided transmural drainage in 10 patients with MP's. A retrospective analysis of patients with pancreatic fluid collections treated with EUS-guided transmural drainage over the last ten years was completed to to identify patients with MP's. Ten patients (8 males, with a mean age of 34.9±9.17 years) with MP treated with EUS-guided transesophageal transmural drainage were identified. Nine patients with MP had concurrent chronic pancreatitis, and only one had MP following acute necrotizing pancreatitis. The mean size of MP was 5.70±1.64 cm, and nine patients (90%) had concurrent abdominal pseudocyst. EUS-guided transesophageal transmural drainage was technically successful in all ten patients. Transmural plastic stents were placed in 9 patients, whereas one patient underwent single-time complete aspiration of the MP. There were no immediate or delayed procedure-related complications. All ten patients had a successful outcome, with the mean resolution time being 2.80±0.79 weeks. There has been no recurrence of PFC or symptoms in nine (90%) successfully treated patients over a mean follow-up period of 43.3 months. EUS-guided trans-esophageal drainage of MP is safe with a high technical and clinical success rate.

Biopsychosocial factors associated with pain severity and hand disability in trapeziometacarpal osteoarthritis and non-surgical management

BackgroundTrapeziometacarpal osteoarthritis (TMO) is one of the most prevalent and painful forms of hand osteoarthritis. PurposeThis study aimed at (1) describing the TMO pain experience, (2) identifying biopsychosocial factors associated with pain intensity and disability, and 3) documenting the use of non-surgical management modalities. Study DesignCross-sectional. MethodsParticipants who presented for care for TMO were recruited from 15 healthcare institutions. They completed a questionnaire addressing sociodemographic, pain, disability, psychological well-being, quality of life (QoL), productivity, and treatment modalities employed. Multivariable regression analyses identified biopsychosocial factors associated with pain intensity and magnitude of disability. ResultsAmong our 228 participants aged 62.6 years, 78.1% were women. More than 80% of the participants reported average pain of moderate to severe intensity in the last 7 days. Nearly 30 % of them scored clinically significant levels of anxiodepressive symptoms. The participants’ norm-based physical QoL score on the SF-12v2 was 41/100. Among the 79 employed respondents, 13 reported having missed complete or part of workdays in the previous month and 18 reported being at risk of losing their job due to TMO. Factors independently associated with more intense pain included higher pain frequency and greater disability, accounting for 59.0% of the variance. The mean DASH score was 46.1 of 100, and the factors associated with greater magnitude of disability were higher pain intensity, greater levels of depression, female sex, and lower level of education, explaining 60.1% of the variance. Acetaminophen, oral non-steroid anti-inflammatory drugs, cortisone injections, orthoses, hand massage/exercises, and heat/cold application were the most frequently employed modalities. Most participants never used assistive devices, ergonomic techniques, and psychosocial services. ConclusionsPatients with TMO can experience severe pain, disability, disturbed emotional well-being, limited QoL and reduced productivity. As disability is associated with TMO pain, and depressive symptoms with disability, reducing such modifiable factors should be one of the clinicians’ priorities.

Evaluating the benefit of surgical resection for hepatocellular carcinoma with multifocality or intrahepatic vascular invasion

BackgroundThe role of hepatectomy for hepatocellular carcinoma (HCC) with multifocality or intrahepatic vascular involvement remains ill-defined. Our objective was to evaluate benefits of surgical resection for patients with these high-risk features. MethodsThe National Cancer Database was used to identify HCC patients with vascular involvement and/or multifocality (T2/T3, N-/M−) from 2011 to 2015. Propensity score matching (k-nearest neighbors, no replacement, 1:1) grouped patients by treatment: surgical resection versus non-surgical modalities. Groups were matched using patient, clinical, and liver-specific characteristics. Median overall survival (OS) was calculated using Kaplan–Meier, and adjusted analyses were performed using shared frailty models. Results14,557 patients met inclusion criteria, including 1892 (9.4%) treated with surgical resection. Median cohort OS was 20.5 months. After adjustment, surgical resection was associated with survival advantage compared to non-surgical treatment (37.8 versus 15.7 months, log-rank P < .001; adjusted hazard ratio 0.49, 95% confidence interval, 0.45–0.54). Patients with minimal comorbidity, unifocal disease, and age <54 had highest probability of survival one year post-surgery. ConclusionsSurgical resection is associated with a survival advantage in HCC with multifocality and/or intrahepatic vascular involvement. The presence of these features should not contraindicate consideration of hepatectomy in suitable surgical candidates.

Peyronie's Disease: An Outcomes-Based Guide to Non-Surgical and Novel Treatment Modalities.

The clinical landscape of Peyronie's disease is everchanging. There has been growing interest in non-invasive therapeutic options that could assist patients with achieving a meaningful reduction in penile curvature without surgical intervention. These therapies are wide-ranging in terms of their mechanisms of action, efficacies, and short- and long-term safety profiles. Recently, an abundance of outcomes literature on longstanding and novel non-surgical treatment modalities has been published. For sexual medicine providers hoping to offer patients the most up-to-date and evidence-based treatments for the management of Peyronie's disease, it can be challenging to gain a thorough understanding of this body of literature. In this clinical management review, the workup and current theories on the pathophysiology of Peyronie's disease are reviewed, and the most recent outcomes data on the currently available non-surgical treatment modalities are presented. With an accurate understanding of the current landscape of Peyronie's disease treatment, sexual health providers will be able to better evaluate and engage in evidence-based shared decision-making with their patients.

The Utility of Lymphatic Massage in Cosmetic Procedures.

Abstract Lymphedema is a severe debilitating disease characterized by the accumulation of excessive protein-rich fluid in the interstitial space. Given the severe morbidity associated with this disease process, various surgical and nonsurgical treatment modalities have been developed to attempt to reduce the incidence and symptoms associated with lymphedema. Manual lymphatic drainage (MLD) is a component of complete decongestive therapy on-surgical treatment which has demonstrated benefit in reducing the development of lymphedema following surgery. Here we provide a review of literature on MLD and its potential mechanism of action. This paper aims to educate patients, physicians, and surgeons about MLD regarding its efficacy and utility in the treatment paradigm for lymphedema and to translate concepts from the treatment of lymphedema to cosmetic procedures. Level of Evidence: 5

Influence of periodontal surgery on the subgingival microbiome-A systematic review and meta-analysis.

The objective of this systematic review and meta-analysis was to evaluate the effect of periodontal surgery on the subgingival microbiome. Periodontitis is a chronic inflammation of the tooth supporting tissues caused by the dysbiosis of the subgingival biofilm. It is managed through different non-surgical and surgical treatment modalities. Recent EFP S3 guidelines recommended performing periodontal surgery as part of Step 3 periodontitis treatment after Step 1 and Step 2 periodontal therapy, with the aim to achieve pocket closure of persisting sites. Changes in the sub-gingival microbiome may explain the treatment outcomes observed at different time points. Various microbiological detection techniques for disease-associated pathogens have been evolved over time and have been described in the literature. However, the impact of different types of periodontal surgery on the subgingival microbiome remains unclear. A systematic literature search was conducted in Medline, Embase, LILACS and Cochrane Library supplemented by manual search (23DEC2019, updated 21APR2022). From an initial search of 3046 studies, 28 were included according to our specific inclusion criteria. Seven microbiological detection techniques were used to analyse disease-associated species in subgingival plaque samples: optical microscope, culture, polymerase chain reaction (PCR), checkerboard, enzymatic reactions, immunofluorescence and 16S gene sequencing. The included studies exhibited differences in various aspects of their methodologies such as subgingival plaque sample collection or treatment modalities. Clinical data showed a significant decrease in probing pocket depths (PPD) and clinical attachment loss (CAL) after periodontal surgery. Microbiological findings were overall heterogeneous. Meta-analysis was performed on a sub-cohort of studies all using checkerboard as a microbiological detection technique. Random effect models for Treponema denticola (T.denticola), Porphyromonas gingivalis (P.gingivalis) and Tannerella forsythia (T.forsythia) did not show a significant effect on mean counts 3 months after periodontal surgery. Notably, Aggregatibacter actinomycetemcomitans (A.actinomycetemcomitans) showed a significant increase 3 months after periodontal surgery. 16S gene sequencing was used in one included study and reported a decrease in disease-associated species with an increase in health-associated species after periodontal surgery at 3 and 6 months. This systematic review has shown that the effect of periodontal surgery on the changes in subgingival microbiome is heterogeneous and may not always be associated with a decrease in disease-associated species. The variability could be attributed to the microbiological techniques employed for the analysis. Therefore, there is a need for well-designed and adequately powered studies to understand how periodontal surgery influences the subgingival microbiome and how the individual's microbiome affects treatment outcomes after periodontal surgery.

Outer cortex thyroid cartilage invasion vs gross extrathyroidal extension in T4a carcinoma larynx: Are they the same entity?

We read the article by Dwivedi et al.[1] with great interest. In the past, total laryngectomy was considered the gold standard treatment for carcinoma larynx regardless of the stage. As the science of conservation laryngectomy, and organ preservation by non-surgical modalities[2] has evolved, total laryngectomy was deemed suitable for very advanced, i.e., T4a lesions of the larynx. T4a is any erosion of the outer cortex of the thyroid cartilage or beyond. This outer cortex erosion can be minimal or gross with soft tissue involvement. The accuracy of computed tomography for detecting gross extrathyroidal extension will obviously be 100%.[3] Now, the question arises as to how to accurately identify early outer cortex erosion of the thyroid cartilage when there is no soft tissue involvement. Guo et al.[4] have beautifully described the computed tomography-based radiomics features for the prediction of thyroid cartilage erosion in laryngeal cancer. A mention of the cases of early outer thyroid cartilage erosion in the study by Dwivedi et al.[1] and their true detection on histopathology would have been appreciated. Of the 30 patients included in this study, nine patients had T2 disease and four had T3 disease. As all patients included in the study underwent total laryngectomy, could they have been offered organ preservation, either medically or surgically? Additionally, the role of computed tomography scans in accurately identifying outer cortex erosion with gross extrathyroidal extension in patients who are post-chemoradiation should be carefully assessed, in view of post-chemoradiation changes in the larynx. Magnetic resonance imaging and a positron emission tomography-computed tomography scan would be valuable to help differentiate edema from tumor in the salvage setting. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.