Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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On Sep 2018




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Prof. Somashekhar Nimbalkar
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Chairman, Research Group, Charutar Arogya Mandal, Karamsad
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Ex-Member, Governing Body, National Neonatology Forum, New Delhi
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Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
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Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
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Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




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Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




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C.S. Ramesh Babu,
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On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
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Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


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Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
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In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
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Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2023 | Month : January | Volume : 17 | Issue : 1 | Page : ZK01 - ZK03 Full Version

Efficacy of Three Different Photobiomodulation Therapies on Primary and Secondary Implant Stability in D3 and D4 Bone Type- A Research Protocol for Randomised Controlled Trial


Published: January 1, 2023 | DOI: https://doi.org/10.7860/JCDR/2023/59042.17297
Ashika Singhania, Anjali Bhoyar Borle, Seema Sathe

1. Assisstant Professor, Department of Prosthodontics, Sharad Pawar Dental College, Wardha, Maharashtra, India. 2. Professor, Department of Prosthodontics, Sharad Pawar Dental College, Wardha, Maharashtra, India. 3. Professor, Department of Prosthodontics, Sharad Pawar Dental College, Wardha, Maharashtra, India.

Correspondence Address :
Ashika Singhania,
Singhania House, Shivnagar, Wardha, Maharashtra, India.
E-mail: aaaashi3@gmail.com

Abstract

Introduction: Osseointegration is considered one of the most important deciding factors to check for implant stability, which decides successful outcome of the implant. Photobiomodulation has been used to improve the implant stability by enhancing osseointegration. Photobiomodulation (PBM) or Low-level Laser Therapy (LLLT) causes an enhanced effect in the bone implant contact.

Need for the Study: There are no definitive therapies/protocol of LLLT in cases of bone density of D3 and D4. Also There are no studies in literature which compares the different laser settings so that a standardised setting can be established. Therefore, there is need to generate evidence whether reducing the number of appointments and reducing the amount of energy given in D3 and D4(compromised) bone can help achieve early loading in patients.

Aim: To evaluate and compare the effect of three different photobiomodulation therapies on primary and secondary implant stability in D3 and D4 bone type in comparison to control group to achieve early loading.

Materials and Methods: This randomized controlled, double blinded study allocated 108 patients having D3 or D4 bone according to Misch classification into six groups. Three different PBM therapy which is either Therapy A, B or C(placebo) will be used. The implant stability will be measured by Ostell meter in Implant Stability Quotients (ISQ) scale, immediately after surgery, after 3 weeks, after 12 weeks and after 6 months of surgery. The bone density will be measured before surgery and 3 months after surgery.

Expected Outcome: At the end of the study, an evidence will be generated whether reducing the number of appointments and reducing the amount of energy given in D3 and D4(compromised) bone can help achieve early loading in patients. Patients treated using PBM therapy either protocol A or protocol B may show enhanced implant stability.

Keywords

Compromised bone, Early loading, Low level laser therapy, Osseointegration

Exemplary aesthetics, high success rates and functional characteristics has made the field of dental implants very popular, amongst patients with dentition defects. However, risk of failure in implants is still seen in many patients due to lack of osseointegration. A number of factors can influence osseointegration. Various factors like physical, chemical, and biological promotes the process of osseointegration, from which one of the factor is ‘Photobiomodulation therapy (PBMT)’(1). “Photobiomodulation (PBM) is a non invasive treatment that uses light irradiation of low intensity so that the effects are a response to light and not to heat” (2). LLLT or rather called PBM therapy has become popular recently, with its applications in field of dentistry and medicine continuously growing (3).

Lasers at various wavelengths that are popularly used for PBM are visible (660 nm), near-infrared (810 nm and 940 nm), and less often, midinfrared (1,040 nm, 2,940 nm, 9,400 nm, or 10,400 nm). Broad light sources and Light Emitting Diode (LED) are also becoming famous due to enhanced effect, good quality and control that is offered by the latest devices (4). Experimental study have described that PBM invigorates the proliferation and differentiation of osteoblasts and also it increases the bonding to titanium implant (5).

There is a study that documented that after implant laser irradiation, there was seen an enhanced effect in the stability of implant and the Bone-Implant Contact (BIC). LLLT laser which has a lesser density of energy invigorates the “mitochondrial and cellular membrane photoreceptors” to synthesize Adenosine Tri-Phosphate (ATP), which will further cause an enhancement of cell proliferation rate (6). The stability of implant can be checked using various methods like reverse torque test, shear torque test, percussion test, radiographic analysis, periotest insertion torque test, and resonance frequency analysis (7). Radiographic analysis by Cone Beam Computed Tomography (CBCT) can also help in the evaluation of bone density which can be significantly corresponded with other stability parameters of implant. Therefore, it is possible to predict the initial stability of an implant using CBCT before the placement of an implant (8). Due to high diversity in the methodology related to duration, dosage and energy used in LLLT for which deriving conclusion as to what should be the optimum/ideal range for duration, energy and dosage is not clear. Hence, PBM therapies need to be standardised using laser parameters and RCT with longer follow-up periods, proper sample size calculation, randomisation and blinding method should be conducted to reduce risk of bias. Thus, in this study, a comparison will be done between three different photobiomodulation therapies on primary and secondary implant stability in D3 and D4 bone type in comparison to control group to achieve early loading. Hence, this ptotocol is planned with following objectives:

1. To evaluate the primary and secondary implant stability in D3 and D4 type bone after Photobiomodulation following Low Level Laser Therapy (LLLT) A, LLLT B and therapy C (placebo).
2. To compare the primary and secondary implant stability in D3 and D4 type bone amongst all 6 experimental groups.
3. To assess and compare the effect of therapy A & B as compared to C(control) on implant loading time in D3 and D4 bone type.

This randomised controlled, double blinded trial shall be performed at the Department of Prosthodontics and Crown and Bridge, Sharad Pawar Dental College And Hospital, Wardha, Maharashtra, India. for a period of 3 years. The study began in February 2022 and is going on as per the planned protocol.

Ethical clearance has been obtained from the university with the reference number DMIMS(DU)/IEC/2021/628. The study is registered under registration number CTRI/2022/04/042033

Inclusion criteria: Patients in whom requisite volume of bone for placement of implant is required in such manner that the patient doesn’t have the need for augmentation of bone, patients with missing teeth and those indicated for implant therapy for replacement of same having D3 and D4 type bone quality (150 to 850 Hounsfield units) will be included as cases in the study after taking written informed consent. Healthy men and women patients of age 20-50 years, who have undergone hygienist treatment before clinical trial and have good oral hygiene index will be included as controls in the study.

Exclusion criteria: Those patients with D1, D2 and D5 bone, or having chronic debilitating diseases like Scleroderma, Rheumatoid Arthritis, immunocompromised patients or those with systemic disease (osteoporosis) or with present or past history of deleterious habits (smoking/ tobacco/ alcohol), patients with uncontrolled periodontal disease or who had undergone radiotherapy/ bisphosphonate medication , or patients who will report of taking drugs interfering with wound healing and not willing to participate in the study or report for follow-ups , will be excluded from the study participants.

Sample size calculation: The minimum sample size for each group is 18 according to formula

k=n2/n1=1
where n 1=sample size for group #1,
n 2=sample size for group #2, K=ratio of sample size for group #2 to group #1.

A total of 108 patients reporting to the study centre for implant placement and have D3 or D4 bone type according to Misch classification (9) will be considered for this study.

The experimental groups to be studied shall be as follows (Table/Fig 1).

GROUP 1-Low Level Laser Therapy (LLLT) A in D3 bone
GROUP 2-Low Level Laser Therapy B in D3 bone
GROUP 3-Low Level Laser Therapy C in D3 bone
GROUP 4-Low Level Laser Therapy A in D4 bone
GROUP 5-Low Level Laser Therapy B in D4 bone
GROUP 6-Low Level Laser Therapy C in D4 bone

Laser parameters will be as follows: “Biolase Epic X dental diode laser at a wavelength of 940 nm” for all three protocols (Table/Fig 2). In the systematic review by Yuan Chen (1), the studies which showed a desirable implant stability enhancement were considered as there was no comparison done between the different laser parameters.

All surgical procedures and irradiation procedure will be performed by the same surgeon. The patient irradiation will be performed on randomly selected patients assigned to one of the experimental group following the laid out inclusion and exclusion criteria. The randomisation will be done using computer generated randomisation. The patient shall be blinded about the treatment intervention. Along with the patient, the evaluator will be blinded and he will check the implant stability and bone density changes. The study sequence is described below in a stepwise manner.

Following patient selection and group allocation, the bone density (grey values) of implant site shall be measured using CBCT at three different locations viz. apical, middle and cervical before implant surgery for all the patients. After implant placement, the experimental groups shall receive treatment as per designed PBM therapy which is either Therapy A, B or C which is randomly allocated. The implant stability will be measured by Ostell meter in ISQ scale, immediately after surgery, after three weeks, after 12 weeks and after six months of surgery. The bone density will be measured using Hounsfield units before surgery and three months after surgery. The measurements will be done 5 times and mean results will be evaluated. There will be measurement of bone density (grayscale value) at three levels; cervical, middle, and apical part of each implant. The measurement will be done by CBCT software (Romexis).

The grading for Hounsfield units (HU) will be as follows: (9)

D1: >1250 HU
D2: 850-1250 HU
D3: 350-850 HU
D4: 150-350 HU
D5: <150 HU

EXPECTED OUTCOME

At the end of the study, an evidence will be generated whether reducing the number of appointments and reducing the amount of energy given in D3 and D4(compromised) bone can help achieve early loading in patients.

Patients treated using PBM therapy either Protocol A or Protocol B are expected to show enhanced implant stability.

Discussion

Low Level Laser Therapy (LLLT) or Photobiomodulation (PBM) is an innovational method that can be used to accelerate the healing of bone and also enhance the initial stability of implant. A monochromatic light with a low energy density is applied which will cause non thermal photochemistry effects on cellular level (10). A study conducted by Matys J et al., documented an increase in the stability of implants and the Bone-Implant Contact (BIC) factor, after implant laser irradiation (6). The 635 nm diode laser was used in 40 implants placed in 24 patients with D2 bone. It had two groups control group and patients undergoing LLLT and the study evaluated the implant stability and bone density after LLLT. They reach the conclusion that LLLT enhanced secondary implant stability after four weeks and increased bone density value after 12 weeks at the middle and apical level (6).

Gokmenoglu C et al., conducted a study in 15 partially edentulous patients divided in 2 groups LED and control with Type 2 or Type 3 bone(Lekholm and Zarb). The effect of LED PBM was checked on osseointegration by measuring ISQ values and evaluating Interleukin (IL)-1b, Tumor Growth Factor (TGF)-b, Prostaglandin E2 (PGE2), and Nitric Oxide (NO) levels in the Peri-Implant Crevicular Fluid (PICF) during a 3-month period. They reached a conclusion that LED application to surgical area showed a positive effect on the osseointegration process, and implant stability could be maintained (11).

Gholami L et al., conducted a literature review for in-vivo (animal or clinical) articles until April 2019 wherein only studies with low irradiation doses without any thermal effects used only for their photobiomodulatory purposes were included and positive effects of application of LLLT on most of studies were reported (3). Chen Y et al., conducted a systematic review and reached a conclusion that the present studies conducted were not able to provide enough evidence which will show the positive effects of PBM therapy on implants in patients. Hence, an increased number of high-quality clinical Randomised Controlled Trials (RCTs) are required to verify the data and to draw convincing conclusions (1).

Conclusion

PBM can be achieved using low levels of laser irradiation and seems to be a promising technique due to its positive effects and biomodulatory interaction with cells and living tissue. It was first used in medicine and physiotherapy, but recently it is also finding its way into routine dental practice. This study will help to know the effects of photobiomodulation on osseointegration which will enhance the primary and secondary stability of dental implants.

References

1.
Chen Y, Liu C, Chen X, Mo A. Clinical evidence of photobiomodulation therapy (PBMT) on implant stability and success: A systematic review and meta-analysis. BMC Oral Health. 2019;19:77. https://doi.org/10.1186/s12903-019-0779-4. [crossref] [PubMed]
2.
Mergoni G, Vescovi P, Belletti S, Uggeri J, Nammour S, Gatti R, et al. Effects of 915 nm laser irradiation on human osteoblasts: a preliminary in vitro study. Lasers Med Sci. 2018;33(6):1189-95. [crossref] [PubMed]
3.
Gholami L, Asefi S, Hooshyarfard A, Sculean A, Romanos G, Aoki A, et al. Photobiomodulation in Periodontology and Implant Dentistry:Part I. Photobiomodulation. Photomedicine, and Laser Surgery. 2019;37(12):766-83. [crossref] [PubMed]
4.
Tang E, Arany P. Photobiomodulation and implants: implications for dentistry. J Periodontal Implant Sci. 2013;43(6):262-68. [crossref] [PubMed]
5.
Zayed S, Hakim A. Clinical Efficacy of Photobiomodulation on Dental Implant Osseointegration: A Systematic Review. Saudi J Med Med Sci. May-august. 2020;8(2):80-86.
6.
Matys J, Swider K, LeVniak G, Dominiak M, Romeo U. Photobiomodulation by a 635nm Diode Laser on Peri-Implant Bone: Primary and Secondary Stability and Bone Density Analysis- A Randomized Clinical Trial. BioMed Research International. 2019:1-8. Doi: 10.1155/2019/2785302 [crossref] [PubMed]
7.
Kayhan Z, Kazazoglu E. An Overview of Implant Stability Measurement. Mod App Dent Oral Health. 2018;2(5):212-15. [crossref]
8.
Guzzardella G, Torricelli P, Aldini N, Giardino R. Laser technology in orthopedics: Preliminary study on low power laser therapy to improve the bone-biomaterial interface. The International Journal of Artificial Organs. 2001;24(12):898-02. [crossref] [PubMed]
9.
Kim J, Lim Y, Kim B, Lee J. How Do Parameters of Implant Primary Stability Correspond with CT-Evaluated Bone Quality in the Posterior Maxilla?A Correlation Analysis. Materials. 2021;2(14):270. [crossref] [PubMed]
10.
Maluf A, Maluf R, da Rocha Brito C, Franca F, de Brito R. Mechanical evaluation of the influence of low-level laser therapy in secondary stability of implants in mice shinbones. Lasers Med Sci. 2010;25(5):693-98. [crossref] [PubMed]
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Gokmenoglu C, Ozmeric N, Erguder I, Elgun S. The effect of light-emitting diode photobiomodulation on implant stability and biochemical markers in peri-implant crevicular fluid. Photomedicine and Laser Surgery. 2014;32(3):138-45. [crossref] [PubMed]

DOI and Others

DOI: 10.7860/JCDR/2023/59042.17297

Date of Submission: Jul 13, 2022
Date of Peer Review: Sep 17, 2022
Date of Acceptance: Nov 02, 2022
Date of Publishing: Jan 01, 2023

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Jul 14, 2022
• Manual Googling: Sep 16, 2022
• iThenticate Software: Nov 01, 2022 (14%)

ETYMOLOGY: Author Origin

JCDR is now Monthly and more widely Indexed .
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