Local interventions for the management of alveolar osteitis (dry socket).

BACKGROUND: Alveolar osteitis (dry socket) is a complication of dental extractions more often involving mandibular molar teeth. It is associated with severe pain developing 2 to 3 days postoperatively with or without halitosis, a socket that may be partially or totally devoid of a blood clot, and increased postoperative visits. This is an update of the Cochrane Review first published in 2012.  OBJECTIVES: To assess the effects of local interventions used for the prevention and treatment of alveolar osteitis (dry socket) following tooth extraction. SEARCH METHODS: An Information Specialist searched four bibliographic databases up to 28 September 2021 and used additional search methods to identify published, unpublished, and ongoing studies. SELECTION CRITERIA: We included randomised controlled trials of adults over 18 years of age who were having permanent teeth extracted or who had developed dry socket postextraction. We included studies with any type of local intervention used for the prevention or treatment of dry socket, compared to a different local intervention, placebo or no treatment. We excluded studies reporting on systemic use of antibiotics or the use of surgical techniques because these interventions are evaluated in separate Cochrane Reviews. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. We followed Cochrane statistical guidelines and reported dichotomous outcomes as risk ratios (RR) and calculated 95% confidence intervals (CI) using random-effects models. For some of the split-mouth studies with sparse data, it was not possible to calculate RR so we calculated the exact odds ratio (OR) instead. We used GRADE to assess the certainty of the body of evidence. MAIN RESULTS: We included 49 trials with 6771 participants; 39 trials (with 6219 participants) investigated prevention of dry socket and 10 studies (with 552 participants) looked at the treatment of dry socket. 16 studies were at high risk of bias, 30 studies at unclear risk of bias, and 3 studies at low risk of bias. Chlorhexidine in the prevention of dry socket When compared to placebo, rinsing with chlorhexidine mouthrinses (0.12% and 0.2% concentrations) both before and 24 hours after extraction(s) substantially reduced the risk of developing dry socket with an OR of 0.38 (95% CI 0.25 to 0.58; P < 0.00001; 6 trials, 1547 participants; moderate-certainty evidence). The prevalence of dry socket varies from 1% to 5% in routine dental extractions to upwards of 30% in surgically extracted third molars. The number of patients needed to be treated (NNT) with chlorhexidine rinse to prevent one patient having dry socket was 162 (95% CI 155 to 240), 33 (95% CI 27 to 49), and 7 (95% CI 5 to 10) for control prevalence of dry socket 0.01, 0.05, and 0.30 respectively.  Compared to placebo, placing chlorhexidine gel intrasocket after extractions reduced the odds of developing a dry socket by 58% with an OR of 0.44 (95% CI 0.27 to 0.71; P = 0.0008; 7 trials, 753 participants; moderate-certainty evidence). The NNT with chlorhexidine gel (0.2%) to prevent one patient developing dry socket was 180 (95% CI 137 to 347), 37 (95% CI 28 to 72), and 7 (95% CI 5 to 15) for control prevalence of dry socket of 0.01, 0.05, and 0.30 respectively. Compared to chlorhexidine rinse (0.12%), placing chlorhexidine gel (0.2%) intrasocket after extractions was not superior in reducing the risk of dry socket (RR 0.74, 95% CI 0.46 to 1.20; P = 0.22; 2 trials, 383 participants; low-certainty evidence).  The present review found some evidence for the association of minor adverse reactions with use of 0.12%, 0.2% chlorhexidine mouthrinses (alteration in taste, staining of teeth, stomatitis) though most studies were not designed explicitly to detect the presence of hypersensitivity reactions to mouthwash as part of the study protocol. No adverse events were reported in relation to the use of 0.2% chlorhexidine gel placed directly into a socket. Platelet rich plasma in the prevention of dry socket  Compared to placebo, placing platelet rich plasma after extractions was not superior in reducing the risk of having a dry socket (RR 0.51, 95% CI 0.19 to 1.33; P = 0.17; 2 studies, 127 participants; very low-certainty evidence).  A further 21 intrasocket interventions to prevent dry socket were each evaluated in single studies, and there is insufficient evidence to determine their effects. Zinc oxide eugenol versus Alvogyl in the treatment of dry socket Two studies, with 80 participants, showed that Alvogyl (old formulation) is more effective than zinc oxide eugenol at reducing pain at day 7 (mean difference (MD) -1.40, 95% CI -1.75 to -1.04; P < 0.00001; 2 studies, 80 participants; very low-certainty evidence) A further nine interventions for the treatment of dry socket were evaluated in single studies, providing insufficient evidence to determine their effects. AUTHORS' CONCLUSIONS: Tooth extractions are generally undertaken by dentists for a variety of reasons, however, all but five studies included in the present review included participants undergoing extraction of third molars, most of which were undertaken by oral surgeons. There is moderate-certainty evidence that rinsing with chlorhexidine (0.12% and 0.2%) or placing chlorhexidine gel (0.2%) in the sockets of extracted teeth, probably results in a reduction in dry socket. There was insufficient evidence to determine the effects of the other 21 preventative interventions each evaluated in single studies. There was limited evidence of very low certainty that Alvogyl (old formulation) may reduce pain at day 7 in patients with dry socket when compared to zinc oxide eugenol.

Mind the gap: A novel technique for space closure - a case report.

Patients presenting with severe hypodontia can be challenging to manage. They often present with significant spaces within the dental arches and the lack of permanent teeth can make anchorage control difficult. This case report demonstrates a novel technique for diastema closure in a 14-year-old with severe hypodontia. The technique allows maintenance of root parallelism during space closure in cases with reduced anchorage support. The treatment plan was agreed on a multidisciplinary hypodontia clinic and involved an upper sectional fixed orthodontic appliance to close a 7-mm midline diastema aiding subsequent partial denture provision. Treatment commenced by bonding upper primary canines and central incisors. However, attempting space closure on a 0.019 × 0.025-inch stainless-steel working archwire resulted in tipping of the incisor crowns. Two brackets were therefore placed on the labial surface of each central incisor (one incisal and one gingival). Subsequently two stainless steel working archwires and elastomeric chain were used for diastema closure. This four-bracket system provided superior control allowing space closure by bodily tooth movement. Excellent root parallelism was achieved with this innovative technique.

What are the important outcomes in traumatic dental injuries? An international approach to the development of a core outcome set.

BACKGROUND/AIMS: There are numerous treatment options following traumatic dental injury (TDI). Systematic reviews of different treatments are challenging owing to the diversity of outcomes reported between clinical studies. This issue could be addressed through the development and implementation of a agreed and standardized collection of outcomes known as a core outcome set (COS). The aim of this study was to develop a COS for TDI in children and adults. The secondary aim was to establish what, how, when and by whom these outcomes should be measured. MATERIALS AND METHOD: The project was registered with Core Outcomes Measures in Effectiveness Trials (COMET). A web-based survey was developed to capture the opinions of dentists globally as to which outcomes should be recorded. A list of outcomes was entered into a Delphi Survey and scored by an Expert Working Group (EWG). The scoring was repeated, followed by conference calls to discuss, refine and finalize the COS. The EWG split into small groups of subject-specific experts to determine how, when and by whom each outcome would be measured. RESULTS: The questionnaire was completed by 1476 dentists. The EWG identified 13 core outcomes to be recorded for all TDI's. An additional 10 injury-specific outcomes were identified. A table has been produced for each outcome detailing what, when, and how each outcome should be recorded. CONCLUSIONS: A robust consensus process was used to develop an international COS for TDI in children and adults. This includes both generic and injury-specific outcomes across all identified domains.

The British Orthodontic Society MOrth cases prize 2014.

This paper describes the orthodontic treatment of two cases that were successful in winning the British Orthodontic Society (BOS) Membership in Orthodonitcs (MOrth) cases prize in 2014. The first case describes the management of a 26-year-old female with a Class II division 2 incisor relationship on a Class III skeletal base with reduced vertical proportions. This was complicated by: an unerupted ectopic palatally displaced upper right permanent canine, an erupted palatally displaced upper left permanent canine, retained deciduous canines, generalised microdontia, an overall Bolton tooth size discrepancy, mild crowding in the upper arch, an increased overbite (complete to tooth tissue) and crossbites. Treatment involved a surgical exposure of the ectopic canine and the use of fixed pre-adjusted edgewise appliances over a period of 24 months. The second case describes the management of a 12-year-old female with a Class II division 2 incisor relationship on a Class 2 skeletal base with reduced vertical proportions. This was complicated by: an increased overjet and overbite (complete to soft tissue), mild upper and lower arch crowding and an increased naso-labial angle. Treatment involved an initial phase of modified Clark Twin Block and sectional fixed appliances followed by complete fixed pre-adjusted edgewise appliances over a period of 24 months.

Dental Anxiety- Understanding is the Key to Effective Management.

Dental anxiety (DA) is a common problem; the latest Adult Dental Health Survey (UK) reported nearly half of the adult population experienced anxiety when visiting the dentist. Given individual differences in the experience of dental anxiety, it is important for the dentist to understand its development, detection and management. This article aims to provide an overview of the main psychological theories to explain the development of dental anxiety (behavioural, psychoanalytical and cognitive), as well as an overview of anxiety detection and management techniques from a psychological perspective. Clinical relevance: Dental anxiety is a common barrier to oral healthcare, with nearly half of the UK population affected. By understanding its causes, effective management can reduce anxiety, and therefore barriers to achieving high standards of oral health can be overcome.

Interventions for the treatment of keratocystic odontogenic tumours.

BACKGROUND: The keratocystic odontogenic tumours (KCOTs) account for between about 2% and 11% of all jaw cysts and can occur at any age. They are more common in males than females with a male:female ratio of approximately 2:1. Although they are benign, KCOTs are locally very aggressive and have a tendency to recur after treatment. Reported recurrence rates range from 3% to 60%. The traditional method for the treatment of most KCOTs is surgical enucleation. However, due to the lining of the cyst being delicate and the fact that they frequently recur, this method alone is not sufficient. Adjunctive surgical treatment has been proposed in addition to the surgical enucleation, such as removal of the peripheral bone (ostectomy) or resection of the cyst with surrounding bone (en-bloc) resection. Other adjunctive treatments proposed are: cryotherapy (freezing) with liquid nitrogen and the use of the fixative Carnoy's solution placed in the cyst cavity after enucleation; both of which attempt to address residual tissue to prevent recurrence. OBJECTIVES: To assess the available evidence comparing the effectiveness of interventions for the treatment of KCOTs. SEARCH METHODS: We searched the following electronic databases: the Cochrane Oral Health Group Trials Register (to 17 March 2015), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2015, Issue 2), MEDLINE via Ovid (1946 to 17 March 2015) and EMBASE via Ovid (1980 to 17 March 2015). We searched the US National Institutes of Health Trials Register (http://clinicaltrials.gov) and the WHO Clinical Trials Registry Platform for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. SELECTION CRITERIA: Randomised controlled trials comparing one modality of intervention with another with or without adjunctive treatment for the treatment of KCOTs. Adults, over the age of 18 with a validated diagnosis of solitary KCOTs arising in the jaw bones of the maxilla or mandible. Patients with known Gorlin syndrome were to be excluded. DATA COLLECTION AND ANALYSIS: Review authors screened trials for inclusion. Full papers were obtained for relevant and potentially relevant trials. If data had been extracted, it would have been synthesised using the fixed-effect model, if substantial clinical diversity were identified between studies we planned to use the random-effects model with studies grouped by action provided there were four or more studies included in the meta-analysis, and we would have explored the heterogeneity between the included studies. MAIN RESULTS: No randomised controlled trials that met the inclusion criteria were identified. AUTHORS' CONCLUSIONS: There are no published randomised controlled trials relevant to this review question, therefore no conclusions could be reached about the effectiveness or otherwise of the interventions considered in this review. There is a need for well designed and conducted randomised controlled trials to evaluate treatments for KCOTs.

Xylitol-containing products for preventing dental caries in children and adults.

BACKGROUND: Dental caries is a highly prevalent chronic disease which affects the majority of people. It has been postulated that the consumption of xylitol could help to prevent caries. The evidence on the effects of xylitol products is not clear and therefore it is important to summarise the available evidence to determine its effectiveness and safety. OBJECTIVES: To assess the effects of different xylitol-containing products for the prevention of dental caries in children and adults. SEARCH METHODS: We searched the following electronic databases: the Cochrane Oral Health Group Trials Register (to 14 August 2014), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2014, Issue 7), MEDLINE via OVID (1946 to 14 August 2014), EMBASE via OVID (1980 to 14 August 2014), CINAHL via EBSCO (1980 to 14 August 2014), Web of Science Conference Proceedings (1990 to 14 August 2014), Proquest Dissertations and Theses (1861 to 14 August 2014). We searched the US National Institutes of Health Trials Register (http://clinicaltrials.gov) and the WHO Clinical Trials Registry Platform for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. SELECTION CRITERIA: We included randomised controlled trials assessing the effects of xylitol products on dental caries in children and adults. DATA COLLECTION AND ANALYSIS: Two review authors independently screened the results of the electronic searches, extracted data and assessed the risk of bias of the included studies. We attempted to contact study authors for missing data or clarification where feasible. For continuous outcomes, we used means and standard deviations to obtain the mean difference and 95% confidence interval (CI). We used the continuous data to calculate prevented fractions (PF) and 95% CIs to summarise the percentage reduction in caries. For dichotomous outcomes, we reported risk ratios (RR) and 95% CIs. As there were less than four studies included in the meta-analysis, we used a fixed-effect model. We planned to use a random-effects model in the event that there were four or more studies in a meta-analysis. MAIN RESULTS: We included 10 studies that analysed a total of 5903 participants. One study was assessed as being at low risk of bias, two were assessed as being at unclear risk of bias, with the remaining seven being at high risk of bias.The main finding of the review was that, over 2.5 to 3 years of use, a fluoride toothpaste containing 10% xylitol may reduce caries by 13% when compared to a fluoride-only toothpaste (PF -0.13, 95% CI -0.18 to -0.08, 4216 children analysed, low-quality evidence).The remaining evidence on children, from small single studies with risk of bias issues and great uncertainty associated with the effect estimates, was insufficient to determine a benefit from xylitol products. One study reported that xylitol syrup (8 g per day) reduced caries by 58% (95% CI 33% to 83%, 94 infants analysed, low quality evidence) when compared to a low-dose xylitol syrup (2.67 g per day) consumed for 1 year.The following results had 95% CIs that were compatible with both a reduction and an increase in caries associated with xylitol: xylitol lozenges versus no treatment in children (very low quality body of evidence); xylitol sucking tablets versus no treatment in infants (very low quality body of evidence); xylitol tablets versus control (sorbitol) tablets in infants (very low quality body of evidence); xylitol wipes versus control wipes in infants (low quality body of evidence).There was only one study investigating the effects of xylitol lozenges, when compared to control lozenges, in adults (low quality body of evidence). The effect estimate had a 95% CI that was compatible with both a reduction and an increase in caries associated with xylitol.Four studies reported that there were no adverse effects from any of the interventions. Two studies reported similar rates of adverse effects between study arms. The remaining studies either mentioned adverse effects but did not report any usable data, or did not mention them at all. Adverse effects include sores in the mouth, cramps, bloating, constipation, flatulence, and loose stool or diarrhoea. AUTHORS' CONCLUSIONS: We found some low quality evidence to suggest that fluoride toothpaste containing xylitol may be more effective than fluoride-only toothpaste for preventing caries in the permanent teeth of children, and that there are no associated adverse-effects from such toothpastes. The effect estimate should be interpreted with caution due to high risk of bias and the fact that it results from two studies that were carried out by the same authors in the same population. The remaining evidence we found is of low to very low quality and is insufficient to determine whether any other xylitol-containing products can prevent caries in infants, older children, or adults.

Replacement versus repair of defective restorations in adults: resin composite.

BACKGROUND: Composite filling materials have been increasingly used for the restoration of posterior teeth in recent years as a tooth-coloured alternative to amalgam. As with any filling material composites have a finite life-span. Traditionally, replacement was the ideal approach to treat defective composite restorations, however, repairing composites offers an alternative more conservative approach to the tooth structure where restorations are partly still serviceable. Repairing the restoration has the potential of taking less time and may sometimes be performed without the use of local anaesthesia hence it may be less distressing for a patient when compared with replacement. OBJECTIVES: To evaluate the effects of replacing (with resin composite) versus repair (with resin composite) in the management of defective resin composite dental restorations in permanent molar and premolar teeth. SEARCH METHODS: For the identification of studies relevant to this review we searched the Cochrane Oral Health Group's Trials Register (to 24 July 2013); the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 6); MEDLINE via OVID (1946 to 24 July 2013); EMBASE via OVID (1980 to 24 July 2013); BIOSIS via Web of Knowledge (1969 to 24 July 2013); Web of Science (1945 to 24 July 2013); and OpenGrey (to 24 July 2013). Researchers, experts and organisations known to be involved in this field were contacted in order to trace unpublished or ongoing studies. No restrictions were placed on the language or date of publication when searching the electronic databases. SELECTION CRITERIA: Trials were selected if they met the following criteria: randomised controlled trial (including split-mouth studies), involving replacement and repair of resin composite restorations in adults with a defective molar restoration in a permanent molar or premolar teeth. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed titles and abstracts for each article identified by the searches in order to decide whether the article was likely to be relevant. Full papers were obtained for relevant articles and both review authors studied these. The Cochrane Collaboration statistical guidelines were to be followed for data synthesis. MAIN RESULTS: The search strategy retrieved 298 potentially eligible studies, after de-duplication. After examination of the titles and abstracts, full texts of potentially relevant studies were retrieved but none of the retrieved studies met the inclusion criteria of the review. AUTHORS' CONCLUSIONS: There are no published randomised controlled trials relevant to this review question. There is therefore a need for methodologically sound randomised controlled trials that are reported according to the Consolidated Standards of Reporting Trials (CONSORT) statement (www.consort-statement.org/). Further research also needs to explore qualitatively the views of patients on repairing versus replacement and investigate themes around pain, anxiety and distress, time and costs.

Replacement versus repair of defective restorations in adults: amalgam.

BACKGROUND: Amalgam is a common filling material for posterior teeth, as with any restoration amalgams have a finite life-span. Traditionally replacement was the ideal approach to treat defective amalgam restorations, however, repair offers an alternative more conservative approach where restorations are only partially defective. Repairing a restoration has the potential of taking less time and may sometimes be performed without the use of local anaesthesia hence it may be less distressing for a patient when compared with replacement. Repair of amalgam restorations is often more conservative of the tooth structure than replacement. OBJECTIVES: To evaluate the effects of replacing (with amalgam) versus repair (with amalgam) in the management of defective amalgam dental restorations in permanent molar and premolar teeth. SEARCH METHODS: For the identification of studies relevant to this review we searched the Cochrane Oral Health Group's Trials Register (to 5 August 2013); the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 7); MEDLINE via OVID (1946 to 5 August 2013); EMBASE via OVID (1980 to 5 August 2013); BIOSIS via Web of Knowledge (1969 to 5 August 2013); Web of Science (1945 to 5 August 2013) and OpenGrey (to 5 August 2013). Researchers, experts and organisations known to be involved in this field were contacted in order to trace unpublished or ongoing studies. No restrictions were placed on the language or date of publication when searching the electronic databases. SELECTION CRITERIA: Trials were selected if they met the following criteria: randomised controlled trial (including split-mouth studies), involving replacement and repair of amalgam restorations in adults with a defective restoration in a molar or premolar tooth/teeth. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed titles and abstracts for each article identified by the searches in order to decide whether the article was likely to be relevant. Full papers were obtained for relevant articles and both review authors studied these. The Cochrane Collaboration statistical guidelines were to be followed for data synthesis. MAIN RESULTS: The search strategy retrieved 201 potentially eligible studies after de-duplication. After examination of the titles and abstracts, full texts of the relevant studies were retrieved but none of these met the inclusion criteria of the review. AUTHORS' CONCLUSIONS: There are no published randomised controlled trials relevant to this review question. There is therefore a need for methodologically sound randomised controlled trials that are reported according to the Consolidated Standards of Reporting Trials (CONSORT) statement (www.consort-statement.org/). Further research also needs to explore qualitatively the views of patients on repairing versus replacement and investigate themes around pain, distress and anxiety, time and costs.

Local interventions for the management of alveolar osteitis (dry socket).

BACKGROUND: Alveolar osteitis (dry socket) is a complication of dental extractions and occurs more commonly in extractions involving mandibular molar teeth. It is associated with severe pain developing 2 to 3 days postoperatively, a socket that may be partially or totally devoid of blood clot and in some patients there may be a complaint of halitosis. It can result in an increase in postoperative visits. OBJECTIVES: To assess the effects of local interventions for the prevention and treatment of alveolar osteitis (dry socket) following tooth extraction. SEARCH METHODS: The following electronic databases were searched: the Cochrane Oral Health Group Trials Register (to 29 October 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 10), MEDLINE via OVID (1946 to 29 October 2012) and EMBASE via OVID (1980 to 29 October 2012). There were no restrictions regarding language or date of publication. We also searched the reference lists of articles and contacted experts and organisations to identify any further studies. SELECTION CRITERIA: We included randomised controlled trials of adults over 18 years of age who were having permanent teeth extracted or who had developed dry socket post-extraction. We included studies with any type of local intervention used for the prevention or treatment of dry socket, compared to a different local intervention, placebo or no treatment. We excluded studies reporting on systemic use of antibiotics or the use of surgical techniques for the management of dry socket because these interventions are evaluated in separate Cochrane reviews. DATA COLLECTION AND ANALYSIS: Two review authors independently undertook risk of bias assessment and data extraction in duplicate for included studies using pre-designed proformas. Any reports of adverse events were recorded and summarised into a table when these were available. We contacted trial authors for further details where these were unclear. We followed The Cochrane Collaboration statistical guidelines and reported dichotomous outcomes as risk ratios (RR) and calculated 95% confidence intervals (CI) using random-effects models. For some of the split-mouth studies with sparse data it was not possible to calculate RR so we calculated the exact odds ratio instead. We used the GRADE tool to assess the quality of the body of evidence. MAIN RESULTS: Twenty-one trials with 2570 participants met the inclusion criteria; 18 trials with 2376 participants for the prevention of dry socket and three studies with 194 participants for the treatment of dry socket. The risk of bias assessment identified six studies at high risk of bias, 14 studies at unclear risk of bias and one studies at low risk of bias. When compared to placebo, rinsing with chlorhexidine mouthrinses (0.12% and 0.2% concentrations) both before and after extraction(s) prevented approximately 42% of dry socket(s) with a RR of 0.58 (95% CI 0.43 to 0.78; P < 0.001) (four trials, 750 participants, moderate quality of evidence). The prevalence of dry socket varied from 1% to 5% in routine dental extractions to upwards of 30% in surgically extracted third molars. The number of patients needed to be treated with (0.12% and 0.2%) chlorhexidine rinse to prevent one patient having dry socket (NNT) was 232 (95% CI 176 to 417), 47 (95% CI 35 to 84) and 8 (95% CI 6 to 14) for control prevalences of dry socket of 1%, 5% and 30% respectively.Compared to placebo, placing chlorhexidine gel (0.2%) after extractions prevented approximately 58% of dry socket(s) with a RR of 0.42 (95% CI 0.21 to 0.87; P = 0.02) (two trials, in 133 participants, moderate quality of evidence). The number of patients needed to be treated with chlorhexidine gel to prevent one patient having dry socket (NNT) was 173 (95% CI 127 to 770), 35 (95% CI 25 to 154) and 6 (95% CI 5 to 26) for control prevalences of dry socket of 1%, 5% and 30% respectively.A further 10 intrasocket interventions to prevent dry socket were each evaluated in single studies, and therefore there is insufficient evidence to determine their effects. Five interventions for the treatment of dry socket were evaluated in a total of three studies providing insufficient evidence to determine their effects. AUTHORS' CONCLUSIONS: Most tooth extractions are undertaken by dentists for a variety of reasons, however, all but three studies included in the present review included participants undergoing extraction of third molars, most of which were undertaken by oral surgeons. There is some evidence that rinsing with chlorhexidine (0.12% and 0.2%) or placing chlorhexidine gel (0.2%) in the sockets of extracted teeth, provides a benefit in preventing dry socket. There was insufficient evidence to determine the effects of the other 10 preventative interventions each evaluated in single studies. There was insufficient evidence to determine the effects of any of the interventions to treat dry socket. The present review found some evidence for the association of minor adverse reactions with use of 0.12%, 0.2% and 2% chlorhexidine mouthrinses, though most studies were not designed to detect the presence of hypersensitivity reactions to mouthwash as part of the study protocol. No adverse events were reported in relation to the use of 0.2% chlorhexidine gel placed directly into a socket (though previous allergy to chlorhexidine was an exclusion criterion in these trials). In view of recent reports in the UK of two cases of serious adverse events associated with irrigation of dry socket with chlorhexidine mouthrinse, it is recommended that all members of the dental team prescribing chlorhexidine products are aware of the potential for both minor and serious adverse side effects.

Consent and parental responsibility - the past, the present and the future.

Introduction Informed consent is the 'permission or agreement' given by the patient for a proposed action. This paper explores the clinician's role in obtaining informed consent, provides an overview of consent and parental responsibility in the UK, and presents practical adjuncts to aid dental professionals in ascertaining who has parental responsibility to delineate persons capable of providing assent on behalf of an underage patient.Consent and parental responsibility While the principles of consent have largely stayed constant with time, subtleties in parental responsibility legislation exist in different regions of the UK. An audit exploring consent and parental responsibility knowledge among clinicians within the orthodontic department at the UCLH Eastman Dental Hospital demonstrated that none of the respondents met the gold standard (100%). The results ranged from 59-89% with a mean score of 74%. The majority of questions answered incorrectly related to knowledge of parental responsibility.Conclusion It is the responsibility of clinicians providing any care within the UK to stay up to date with legislation and regulations regarding consent and parental responsibility. Knowledge-based questionnaires can highlight areas of knowledge deficit which can be addressed through continuous professional development. This paper provides a flowchart summarising parental responsibility and a prefilled parental responsibility questionnaire as adjuncts to simplify the process of dental professionals ascertaining parental responsibility.

Making the grade? Modification of dental radiograph quality ratings.

AIMS: To compare the intra- and inter-assessor agreement and operator preference of a modified (four-grade) quality rating system for dental radiographs with the current National Radiological Protection Board (NRPB) (three-grade) quality rating system. METHODS: Sixty radiographic images of varying quality were selected by retrospective review of dental records from a general dental practice. The images were sorted into groups to represent examples of radiographic quality (1=excellent, 2=diagnostically acceptable, 3=diagnostically compromised, 4=unacceptable). A 'gold standard' for radiological quality assessment was provided by a consultant in dental and maxillofacial radiology. A compact disc (CD) of the 60 images was produced and posted to a panel of 14 general dental practitioners (GDPs) who were asked to grade the quality of the images using two different systems on two occasions separated by a washout period of two days. The practitioners graded the radiographs using the currently accepted method for assessing radiographic quality (the three-grade NRPB system) and the alternative four-grade system. The quality of the images on the CD was deemed appropriate by the consultant. RESULTS: The strength of inter-assessor agreement was weaker when using a four-grade system in comparison to a three-grade system, reducing to a mean of k=0.51 from a mean of k=0.61 when using the original grading system. Mean agreement did not fall below 'moderate agreement' (k=0.41-0.60). Eleven of the 14 GDPs preferred the four-grade system. CONCLUSION: The GDPs who participated in this study preferred the four-grade system to the three-grade system when comparing the quality of dental radiographs. However, the strength of agreement was weaker when using the four-grade system in comparison to the three-grade system. Overall, the results are equivocal. However, they should help to inform specialist dental radiology panels, should revision of quality grading be undertaken in the future.

Interventions for the treatment of keratocystic odontogenic tumours (KCOT, odontogenic keratocysts (OKC)).

BACKGROUND: The keratocystic odontogenic tumours (KCOTs) account for between about 2% and 11% of all jaw cysts and can occur at any age. They are more common in males than females with a male:female ratio of approximately 2:1. Although they are benign, KCOTs are locally very aggressive and have a tendency to recur after treatment, reported recurrence rates range from 3% to 60%. The traditional method for the treatment of most KCOTs is surgical enucleation. However, due to the lining of the cyst being delicate and the fact that they frequently recur, this method alone is not sufficient. Adjunctive surgical treatment has been proposed in addition to the surgical enucleation, such as removal of the peripheral bone (ostectomy) or resection of the cyst with surrounding bone (en-bloc) resection. Other adjunctive treatments proposed are: cryotherapy (freezing) with liquid nitrogen and the use of the fixative Carnoy's solution placed in the cyst cavity after enucleation; both of which attempt to address residual tissue to prevent recurrence. OBJECTIVES: To assess the available evidence comparing the effectiveness of surgical interventions and adjuncts for the treatment of KCOTs. SEARCH STRATEGY: Databases searched were: the Cochrane Oral Health Group's Trials Register (to 28th July 2010), CENTRAL (The Cochrane Library 2010, Issue 3), MEDLINE (from 1950 to 28th July 2010), and EMBASE (from 1980 to 28th July 2010). The reference lists of all trials identified were cross checked for additional trials. There were no language restrictions and several articles were translated. SELECTION CRITERIA: Randomised controlled trials comparing one modality of surgical intervention with another with or without adjunctive treatment for the treatment of KCOTs. Adults, over the age of 18 with a validated diagnosis of solitary KCOTs arising in the jaw bones of the maxilla or mandible. Patients with known Gorlin syndrome were to be excluded. DATA COLLECTION AND ANALYSIS: Review authors screened trials for inclusion. Full papers were obtained for relevant and potentially relevant trials. If data had been extracted, it would have been synthesised using the fixed-effect model, if substantial clinical diversity were identified between studies we planned to use the random-effects model with studies grouped by action provided there were four or more studies included in the meta-analysis, and we would have explored the heterogeneity between the included studies. MAIN RESULTS: No randomised controlled trials that met the inclusion criteria were identified. AUTHORS' CONCLUSIONS: There are no published randomised controlled trials relevant to this review question, therefore no conclusions could be reached about the effectiveness or otherwise of the interventions considered in this review. There is a need for well designed and conducted randomised controlled trials to evaluate treatments for KCOTs.

Domestic violence screening and intervention programmes for adults with dental or facial injury.

BACKGROUND: Domestic violence exists in all communities across the world. Healthcare services have a pivotal role in the identification, assessment and response to domestic violence. As the face is a common target in assault, dentists and oral and maxillofacial surgeons are in a unique position to screen for domestic violence in the context of presentation of dental and facial injury. Owing to lack of training, dentists and oral and maxillofacial surgeons may not be the best persons to give advice to someone experiencing domestic violence. Improper advice such as encouragement to leave an abusive relationship may escalate the frequency of violence. It may be more appropriate to refer to specialist agencies for intervention and support. It would, therefore be useful to know whether screening and intervention programmes are effective. OBJECTIVES: (1) To assess the benefits and harms of intervention programmes employed to reduce and or prevent domestic violence in adults with dental and/or facial injuries. (2) To assess the benefits and harms of screening and the use of different screening tools in the detection of the proportion of adult victims of domestic violence who present with dental and/or facial injury. SEARCH STRATEGY: The following electronic databases were searched: the Cochrane Oral Health Group Trials Register (to 18 May 2010), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, Issue 2), MEDLINE via OVID (1950 to 18 May 2010), EMBASE via OVID (1980 to 18 May 2010), PsycINFO via OVID (1950 to 18 May 2010), LILACS via BIREME (1982 to 18 May 2010) and CINAHL via EBSCO (1980 to 18 May 2010). There were no restrictions regarding language or date of publication. SELECTION CRITERIA: Randomised controlled trials (RCTs) involving adults aged 16 years and over presenting with dental and/or facial injury relating to domestic violence in any healthcare setting. DATA COLLECTION AND ANALYSIS: Screening of eligible studies was conducted in duplicate and independently by two reviewers. Results were to be expressed as random effects models using mean differences for continuous outcomes and relative risk for dichotomous outcomes with 95% confidence interval. Heterogeneity was to be investigated including both clinical and methodological factors. MAIN RESULTS: No eligible RCTs were identified. AUTHORS' CONCLUSIONS: There is no evidence from RCTs to support or refute that screening for domestic violence in adults with dental or facial injury is beneficial nor that it causes harm. Screening tools to detect domestic violence exist but no RCTs have specifically evaluated their effectiveness for patients presenting with facial and or dental injuries. There is also lack of evidence (from RCTs) that intervention programmes are effective at reducing frequency of physical assaults and at reducing the severity of facial injuries.

Replacement versus repair of defective restorations in adults: amalgam.

BACKGROUND: Amalgam is a common filling material for posterior teeth, as with any restoration amalgams have a finite life-span. Traditionally replacement was the ideal approach to treat defective amalgam restorations, however, repair offers an alternative more conservative approach where restorations are only partially defective. Repairing a restoration has the potential of taking less time and may sometimes be performed without the use of local anaesthesia hence it may be less distressing for a patient when compared with replacement. OBJECTIVES: To evaluate the effectiveness of replacement (with amalgam) versus repair (with amalgam) in the management of defective amalgam dental restorations in permanent molar and premolar teeth. SEARCH STRATEGY: For the identification of studies relevant to this review we searched the Cochrane Oral Health Group Trials Register (to 23rd September 2009); CENTRAL (The Cochrane Library 2009, Issue 4); MEDLINE (1950 to 23rd September 2009); EMBASE (1980 to 23rd September 2009); ISI Web of Science (SCIE, SSCI) (1981 to 22nd December 2009); ISI Web of Science Conference Proceedings (1990 to 22nd December 2009); BIOSIS (1985 to 22nd December 2009); and OpenSIGLE (1980 to 2005). Researchers, experts and organisations known to be involved in this field were contacted in order to trace unpublished or ongoing studies. There were no language limitations. SELECTION CRITERIA: Trials were selected if they met the following criteria: randomised or quasi-randomised controlled trial, involving replacement and repair of amalgam restorations. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed titles and abstracts for each article identified by the searches in order to decide whether the article was likely to be relevant. Full papers were obtained for relevant articles and both review authors studied these. The Cochrane Collaboration statistical guidelines were to be followed for data synthesis. MAIN RESULTS: The search strategy retrieved 145 potentially eligible studies, after de-duplication and examination of the titles and abstracts all but three studies were deemed irrelevant. After further analysis of the full texts of the three studies identified, none of the retrieved studies met the inclusion criteria and all were excluded from this review. AUTHORS' CONCLUSIONS: There are no published randomised controlled clinical trials relevant to this review question. There is therefore a need for methodologically sound randomised controlled clinical trials that are reported according to the Consolidated Standards of Reporting Trials (CONSORT) statement (www.consort-statement.org/). Further research also needs to explore qualitatively the views of patients on repairing versus replacement and investigate themes around pain, distress and anxiety, time and costs.

Replacement versus repair of defective restorations in adults: resin composite.

BACKGROUND: Composite filling materials have been increasingly used for the restoration of posterior teeth in recent years as a tooth coloured alternative to amalgam. As with any filling material composites have a finite life-span. Traditionally, replacement was the ideal approach to treat defective composite restorations, however, repairing composites offers an alternative more conservative approach where restorations are partly still serviceable. Repairing the restoration has the potential of taking less time and may sometimes be performed without the use of local anaesthesia hence it may be less distressing for a patient when compared with replacement. OBJECTIVES: To evaluate the effectiveness of replacement (with resin composite) versus repair (with resin composite) in the management of defective resin composite dental restorations in permanent molar and premolar teeth. SEARCH STRATEGY: For the identification of studies relevant to this review we searched the Cochrane Oral Health Group Trials Register (to 23rd September 2009); CENTRAL (The Cochrane Library 2009, Issue 4); MEDLINE (1950 to 23rd September 2009); EMBASE (1980 to 23rd September 2009); ISI Web of Science (SCIE, SSCI) (1981 to 22nd December 2009); ISI Web of Science Conference Proceedings (1990 to 22nd December 2009); BIOSIS (1985 to 22nd December 2009); and OpenSIGLE (1980 to 2005). Researchers, experts and organisations known to be involved in this field were contacted in order to trace unpublished or ongoing studies. There were no language limitations. SELECTION CRITERIA: Trials were selected if they met the following criteria: randomised or quasi-randomised controlled trial, involving replacement and repair of resin composite restorations. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed titles and abstracts for each article identified by the searches in order to decide whether the article was likely to be relevant. Full papers were obtained for relevant articles and both review authors studied these. The Cochrane Collaboration statistical guidelines were to be followed for data synthesis. MAIN RESULTS: The search strategy retrieved 279 potentially eligible studies, after de-duplication and examination of the titles and abstracts all but four studies were deemed irrelevant. After further analysis of the full texts of the four studies identified, none of the retrieved studies met the inclusion criteria and all were excluded from this review. AUTHORS' CONCLUSIONS: There are no published randomised controlled clinical trials relevant to this review question. There is therefore a need for methodologically sound randomised controlled clinical trials that are reported according to the Consolidated Standards of Reporting Trials (CONSORT) statement (www.consort-statement.org/). Further research also needs to explore qualitatively the views of patients on repairing versus replacement and investigate themes around pain, anxiety and distress, time and costs.

Interventions for the treatment of fractures of the mandibular condyle.

BACKGROUND: Fractures of the condylar process account for between 25% and 35% of all mandibular fractures. Treatment options for fractures of the condyles consist of either the closed method or by open reduction with fixation. Complications may be associated with either treatment option; for the closed approach these can include malocclusion, particularly open bites, reduced posterior facial height and facial asymmetry in addition to chronic pain and reduced mobility. A cutaneous scar and temporary paralysis of the facial nerve are not infrequent complications associated with the open approach. There is a lack of consensus currently surrounding the indications for either surgical or non-surgical treatment of fractures of the mandibular condyle. OBJECTIVES: To evaluate the effectiveness of interventions that can be used in the treatment of fractures of the mandibular condyle. SEARCH STRATEGY: The databases searched were: the Cochrane Oral Health Group's Trials Register (to 12th March 2010), CENTRAL (The Cochrane Library 2010, Issue 2), MEDLINE (from 1950 to 12th March 2010), and EMBASE (from 1980 to 12th March 2010). The reference lists of all trials identified were cross checked for additional trials. Authors were contacted by electronic mail to ask for details of additional published and unpublished trials. There were no language restrictions and several articles were translated. SELECTION CRITERIA: Randomised controlled trials (RCTs) which included adults, over 18 years of age, with unilateral or bilateral fractures of the mandibular condyles. Any form of open or closed method of reduction and fixation was considered. DATA COLLECTION AND ANALYSIS: Review authors screened trials for inclusion. Extracted data were to be synthesised using the fixed-effect model but if substantial clinical diversity was identified between the studies we planned to use the random-effects model with studies grouped by action and we would explore the heterogeneity between the included studies. Mean differences were to be calculated for continuous outcomes and risk ratios for dichotomous outcomes together with their 95% confidence intervals. MAIN RESULTS: No high quality evidence matching the inclusion criteria was identified. AUTHORS' CONCLUSIONS: No high quality evidence is available in relation to this review question and no conclusions could be reached about the effectiveness or otherwise of the two interventions considered in this review. A need for further well designed randomised controlled trials exists. The trialists should account for all losses to follow-up and assess patient related outcomes. They should also report the direct and indirect costs associated with the interventions.

Patients' knowledge of risk factors for dental disease. A pilot service evaluation in a general dental practice.

UNLABELLED: The major dental diseases, including erosion, caries and periodontal disease, are preventable, and the Department of Health has produced guidelines in a 'Prevention Toolkit' to aid prevention of these diseases in primary care. AIM: To investigate patients' knowledge of the key themes in the Prevention Toolkit and to compare their knowledge of the different dental diseases. METHODS: Patients attending a general dental practice in North West England were asked to complete a questionnaire while they waited to see their dentist. The questionnaire had been piloted for readability, relevance of questions, and ease of use. It included nine true/false questions on key prevention messages. Data from the respondents were used to assess whether there were differences in knowledge by age or gender and between the types of dental diseases. Results were analysed using chi-square tests. RESULTS: 105 patients completed the questionnaire. Of the 420 questions relating to periodontal diseases, 322 (77%) were answered correctly and 196 (47%) of the 420 questions on caries were answered correctly; however, only 32 (31%) of the 105 questions relating to erosion were answered correctly. There were significantly lower levels of knowledge of caries (P<0.01) compared with periodontal diseases. Worryingly, 47 (45%) of 105 respondents stated incorrectly that brushing teeth immediately after consuming a 'fizzy' drink would protect the teeth. CONCLUSION: The results of this pilot service evaluation indicate that in the practice concerned, more needs to be done to promote disease prevention at the primary care level. The current questionnaire could form a valuable tool to audit and reinforce patients' knowledge, although it needs further development and validation. Longitudinal evaluation of the questionnaire, linking it with disease outcome measures, has the potential to indicate whether change in knowledge translates into behavioural change.

General Data Protection Regulation - are we up to date?

Introduction The General Data Protection Regulation (GDPR) is now at the core of data protection and provides more rights than ever before for individuals to control the data that is held about them, and holds organisations accountable.Materials and methods Questionnaire-based knowledge audit consisting of 18 questions relating to GDPR, which was created and distributed to all staff at departmental audit meetings. The gold standard was set that all members of staff were required to pass the questionnaire, with the pass mark set at 14/18. This was followed by a tailored teaching session in conjunction with an online delivery element.Results Cycle 1 was completed in December 2018; the pass rate was 1.6% (1/63) with a response rate of 87.5% (63/72). Scores ranged from 5-14 out of 18. Following dissemination of results, a tailored teaching session was conducted in conjunction with online learning. Cycle 2 was completed in February 2019; the pass rate was 83.9% (47/56) with a response rate of 77.7% (56/72). Scores ranged from 3-18 out of 18.Conclusions Initially, staff knowledge of GDPR was inadequate. Staff knowledge improved with tailored teaching; however, knowledge and understanding of GDPR requires further improvement to meet the gold standard. Therefore, repeat cycles of tailored teaching and audit are planned. It is important that all staff have a good understanding and working knowledge of GDPR to ensure compliance in all areas of practice.