Prevención de osteonecrosis asociada a medicamentos y ensayo clínico multicéntrico, Facultad de Odontología, Universidad de Buenos Aires / Prevention of drug-related osteonecrosis and multicentric clinical trial, School of Dentistry, University of Buenos Aires

La osteonecrosis asociada a medicamentos (ONAM) es un efecto adverso poco frecuente pero potencialmente serio que afecta a pacientes que reciben o recibieron tratamiento con drogas antirresortivas o antiangiogénicas. A partir de una revisión narrativa de la literatura, el presente artículo aporta conceptos básicos e información actualizada acerca de incidencia, factores de riesgo y prevención de ONAM desde la perspectiva de la Práctica Basada en la Evidencia. Además pone en conocimiento a la comunidad profesional de la Facultad de Odontología de la Universidad de Buenos Aires acerca de las actividades de investigación clínica llevadas a cabo en este área en la Cátedra de Cirugía y Traumatología Buco-Máxilo-Facial I de nuestra casa de estudios (AU)

Medicine related osteonecrosis of the jaws (MRONJ) is a rare but potentially serious side effect experienced by patients receiving treatment with antiresorptive or antiangiogenic drugs. Through a narrative review of the literature, this paper provides basic concepts and updated data about incidence, risk factors and prevention of MRONJ from the Evidence Based Practice perspective. It also informs the professional community of the School of Dentistry of the University of Buenos Aires about the clinical research activities carried out in this area in the Oral and Maxillofacial Surgery I Department (AU)

The efficacy of articaine and lidocaine local anaesthetic in child patients.

Data sourcesCochrane CENTRAL Register of Controlled Trials, Medline, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, SCIEXPANDED (ISI Web of Knowledge).Study selectionTwo reviewers selected randomised clinical trials (RCTs) that compared the efficacy of articaine and lidocaine in pain rating during dental treatment in child patients.Data extraction and synthesisTwo authors extracted data using a standardised form, and risk of bias was assessed based on Cochranes Risk of bias tool for RCTs. Meta-analysis was performed on all included studies (n=6) where self-reported pain during and after dental procedure was recorded, and which compared articaine local anaesthesia (LA) to lidocaine LA in children. Then a sensitive analysis was performed excluding the studies with high overall risk of bias (n=3).ResultsSix studies were included, one had 'low', two had 'moderate/uncertain' and three had 'high' risk of bias. To evaluate the impact of these studies with 'high' overall risk of bias, a sensitivity analysis was performed and even when excluding these studies, children who had articaine reported significantly less pain after procedure. However, during the procedure no difference was found between self-reported pain when articaine infiltration and lidocaine inferior dental nerve block were compared.ConclusionsLow quality evidence suggests no difference in efficacy between lidocaine Inferior alveolar dental nerve blocks and articaine infiltration when used for routine dental treatment in children. Also, no difference was found in self-reported pain between lidocaine and articaine during treatment procedures, but apparently articaine leads to less pain reporting after the procedure. The body of the evidence is quite low due to the substantial heterogeneity in the reported outcomes and the overall high risk of bias of the included studies.

Maximising paediatricians' roles in improving children's oral health: lessons from Leicester.

AIMS: To provide an overview of steps taken to improve oral health in one UK city and to review factors relevant to maximising the contribution that paediatricians (and potentially other health professionals) can make to improving oral health. METHODS: The article provides information on the strategic approach taken in Leicester, one of the most ethnically diverse cities in England, and also one of the most deprived. Over a third of children aged 3 years, and half of those aged 5 years, have experience of obvious dental decay. The collaborative strategic approach taken includes implementing a comprehensive evidence-based early intervention programme from birth (Healthy Teeth, Happy Smiles!) and a focus on professional education and engagement. In order to ensure sustainability and further improvement, wider engagement with paediatricians and other primary care providers is essential and is increasingly recognised by professional bodies.Literature relevant to the factors which inhibit engagement with paediatricians and others is reviewed and highlights issues of knowledge and competency, policies and guidelines, time and capacity and referral and access. CONCLUSION: Children's oral health in England has improved over the last 30 years, but inequalities persist, with those living in areas of higher deprivation experiencing a substantially higher burden of dental disease. The article highlights several potential barriers which can be reduced. Collaboration is encouraged between medical and dental professionals as well as commissioners and providers at both the national and local level in order for oral health to be fully integrated within general health. Such collaboration requires appropriate leadership in order to develop policies that support curriculum changes, drive the implementation of associated guidelines, design integrated healthcare service provision and develop the partnership relationships to support this work.

Preoperative analgesia for children and adolescents to reduce pain associated with dental treatment.

Data sourcesCochrane Oral Health Group's Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), Medline, Embase, LILACS, ISI Web of Science, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform.Study selectionRandomised controlled clinical trials of analgesics given before dental treatment versus placebo or no analgesics in children and adolescents up to 17 years of age. Children and adolescents having dental treatment under sedation (including nitrous oxide/oxygen) or general anaesthesia were excluded.Data extraction and synthesisTwo reviewers independently selected studies, abstracted data and assessed risk of bias. Standard Cochrane methodological approaches were used.ResultsFive trials involving 190 patients were included. None of the studies were at low risk of bias. Three trials involved dental treatment and two involved orthodontic treatment. Three of the included trials compared paracetamol with placebo. Meta-analysis of the two trials showed no evidence of a benefit in taking paracetamol preoperatively; (RR) for postoperative pain of 0.81 (95%CI; 0.53 to 1.22). Four trials compared ibuprofen with placebo. Pooled data from two studies showed a statistically significant mean difference in severity of postoperative pain of -13.44 (95%CI; -23.01 to -3.88) on a visual analogue scale (0 to 100), which indicated a probable benefit. Both trials were at high risk of bias and the quality of the evidence is low.ConclusionsFrom the available evidence, we cannot determine whether or not preoperative analgesics are of benefit in paediatric dentistry for procedures under local anaesthetic. There is probably a benefit in using preoperative analgesics prior to orthodontic separator placement. The quality of the evidence is low. Further randomised clinical trials should be completed with appropriate sample sizes and well defined outcome measures.

Effectiveness of adjunctive interventions for accelerating orthodontic tooth movement: a systematic review of systematic reviews.

This study was aimed to summarise published systematic reviews (SRs) that assess the effects of adjunctive interventions on the acceleration of orthodontic tooth movement (OTM). Electronic and manual searches were performed up to August 2016. Systematic reviews investigating the impact of adjunctive techniques on the promotion of OTM were included. The methodological quality of the included reviews was evaluated using the A Measurement Tool to Assess Systematic Reviews (AMSTAR) scale. The quality of evidence for each intervention was assessed using GRADE. The Jadad decision algorithm was used to select a study to provide body evidence from discordant reviews on the same intervention. A total of 11 SRs were included in this study. AMSTAR scores ranged from 4 to 10 of 11. The quality of evidence ranged from very low to low. The short-term (1-3 months) effects of low-level laser therapy (LLLT, 5 and 8 J cm-2 ) and corticotomy were supported by low-quality evidence. The evidence regarding the efficacy of photobiomodulation, pulsed electromagnetic field, interseptal bone reduction, two vibrational devices (Tooth Masseuse and Orthoaccel) and electrical current was of very low quality. Relaxin injections and extracorporeal shock waves were reported to have no impact on OTM according to low- and very low-quality evidence, respectively. Based on currently available information, we conclude that low-quality evidence indicates that LLLT (5 and 8 J cm-2 ) and corticotomy are effective to promote OTM in the short term. Future high-quality trials are required to determine the optimal protocols, as well as the long-term effects of LLLT and corticotomy, before warranting recommendations for orthodontics clinics.

A Systematic Review of the Cervical Plexus Accessory Innervation and Its Role in Dental Anesthesia.

INTRODUCTION: Accessory innervation (AI) may account for the persistent sensation perceived after successful mandibular anesthesia in the adult patient. The purpose of this systematic review was to record the quality of evidence pertaining to the cervical plexus (CP) AI in dental anesthesia. MATERIALS AND METHODS: Electronic and manual searches were conducted using Ovid and Medline of articles published from 1922 to March of 2015. Studies written in any language were included as long as they involved: (i) humans, animals, and/or cadavers AND (ii) anatomical and/or research anesthetic-technique approaches and/or clinical approaches. Exclusion criteria were (i) maxillary buccal infiltration, (ii) no abstract/paper available, (iii) studies that do not comprise the description of the branches of the CP branches in dentistry and (iv) duplicated articles. The articles were reviewed and graded by levels of evidence (LOE) through a methodological scoring index (MSI). RESULTS: Forty-four out of 185 papers fulfilled the inclusion criteria. One randomized control trial, 3 comprehensive reviews, 1 cohort study, 5 case series/reports, 16 poor-quality cohort and case series/reports and 18 reviews/case, reports/expert opinions were found. Of the 44 publications, there were 4 LOE 1, 1 LOE 2, 5 LOE 3, 20 LOE 4 and 14 LOE 5 studies. CONCLUSIONS: The MSI helped to classify papers LOE in a standardized and objective approach. The objective evidence quality occurrence recorded was found to be LOE 4 (n = 20) > LOE 5 (n = 14) > LOE 3 (n = 5) > LOE 1 (n = 4) > LOE 2 (n = 1). The anatomy of the CP needs to be reexamined and understood in the anatomical literature.

Fluoride Rinses, Gels and Foams: An Update of Controlled Clinical Trials.

AIM: The aim of this conference paper was to systematically review the quality of evidence and summarize the findings of clinical trials published after 2002 using fluoride mouth rinses, fluoride gels or foams for the prevention of dental caries. METHODS: Relevant papers were selected after an electronic search for literature published in English between 2003 and 2014. The included papers were assessed for their risk of bias and the results were narratively synthesized due to study heterogeneity. The quality of evidence was expressed according to GRADE. RESULTS: A total of 19 papers were included (6 on fluoride mouth rinse, 10 on fluoride gel and 3 on fluoride foam); 6 had a low risk of bias while 2 had a moderate risk. All fluoride measures appeared to be beneficial in preventing crown caries and reversing root caries, but the quality of evidence was graded as low for fluoride mouth rinse, moderate for fluoride gel and very low for acidulated fluoride foam. No conclusions could be drawn on the cost-effectiveness. CONCLUSIONS: This review, covering the recent decade, has further substantiated the evidence for a caries-preventive effect of fluoride mouth rinse, fluoride gel and foam, previously established in systematic reviews. The lack of clinical trials free from bias is, however, still a concern, especially for fluoride mouth rinses and fluoride foam. There is also a scientific knowledge gap on the benefit and optimal use of these fluoride supplements in combination with daily tooth brushing with fluoride toothpaste.

Stakeholders' Perceptions About a Newly Established Dental School with a Problem-Based, Student-Led, Patient-Centered Curriculum: A Qualitative Study.

The aim of this study was to explore the perceptions of stakeholders regarding a newly established dental school with a problem-based, student-led, patient-centered curriculum in a community setting. Qualitative methods using 16 semistructured interviews and two focus groups were used to engage a range of stakeholders from students to faculty members to practitioners. Purposive sampling was employed with participants contacted through professional channels. Interview and focus group transcripts were transcribed verbatim. The data were analyzed thematically using an inductive approach. Themes related to preparedness of dental graduates were identified during data analyses. Early clinical exposure with patients in the first year of the course, holistic care using a patient-centered approach, and the acquisition of communication skills, professionalism, team-working skills, reflective practice, and evidence-informed clinical practice were perceived to be key strengths of the curriculum. The participants also expressed the need to strengthen teaching of life sciences and provide additional clinical experience in simulated general dental practice clinics. This study provides insight into the perceptions of a wide range of stakeholders and provides a deeper understanding of the merits and challenges of an innovative undergraduate dental curriculum.

Lack of clinical evidence on low-level laser therapy (LLLT) on dental titanium implant: a systematic review.

Low-level laser therapy (LLLT) has proved to have biostimulating effects on tissues over which they are applied, therefore accelerating the healing process. Most studies in implantology were focused on a reduction of the duration of osseointegration. There exist few articles analyzing the potential effects of these therapies on the osseointegration of titanium dental implants. The aim of this study was to assess the effect of LLLT on the interaction between the bone and the titanium dental implant and the methodological quality of the studies. We conducted an electronic search in PubMed, ISI Web, and Cochrane Library. From 37 references obtained, only 14 articles met the inclusion criteria. The analysis of the studies shows that most of the experiments were performed in animals, which have a high risk of bias from the methodological point of view. Only two studies were conducted in human bone under different conditions. Several protocols for the use of low-power laser and different types of laser for all studies analyzed were used. Although animal studies have shown a positive effect on osseointegration of titanium implants, it can be concluded that it is necessary to improve and define a unique protocol to offer a more conclusive result by meta-analysis.

Pain-Related Temporomandibular Disorder - Current Perspectives and Evidence-Based Management.

Pain-related temporomandibular disorder (TMD) is one of the top three most common chronic pain conditions, along with headaches and back pain. TMD has complex pathophysiology and significant associations with a variety of other chronic pain conditions, eg fibromyalgia, irritable bowel syndrome and migraine. Chronic TMD is associated with a negative impact upon quality of life and high levels of healthcare utility. It is important that clinicians are able to diagnose TMD correctly, provide appropriate management in keeping with current evidence-based practice, and identify when to refer patients to specialist care. The presence of risk factors, eg anxiety, depression, pain-related disability and chronic pain conditions elsewhere in the body, may help to identify which TMD patients require referral for multidisciplinary management. TMD should be managed using a holistic approach, incorporating patient education and encouragement towards self-management. TMD care pathways should consider using the three'pillars'of pain management: physical therapies, pharmacotherapy and clinical psychology.

Treatment planning and dental rehabilitation of periodontally compromised partially edentulous patient: a case report - part II.

When planning a prosthetic rehabilitation of a periodontally compromised case, the clinician is often confronted with difficulties and dilemmas related to selecting the appropriate treatment that would provide long-term successful outcomes in function and esthetics. In such cases, a correct diagnosis and prognosis of the intraoral situation supported by evidence-based dentistry is the basis for the establishment of a proper treatment strategy. In this second part of a two-part treatment planning series, a systematic approach of patient examination and prognosis of each tooth is presented. Furthermore, different removable and fixed treatment possibilities are described and the rationale governing the decision-making process is revealed. The execution of the final treatment plan as specified by the concept of comprehensive dental care is outlined, and the final outcome is discussed according to the literature.

Developing pathways for oral care in elders: evidence-based interventions for dental caries prevention in dentate elders.

BACKGROUND: Dental caries is becoming an ever-growing challenge as the number of elders maintaining their teeth increases. There is a need for low-cost, effective preventive interventions to retain natural teeth for elders. OBJECTIVE: The purpose of this article is to evaluate evidence based interventions for dentate elders, specifically the adjunct therapies of fluoride, chlorhexidine, xylitol, casein phosphopeptide-amorphous calcium phosphate, ozone, and herbal liquorice. RESULTS: Fluoride interventions have demonstrated prevention and remineralization of dental caries in elders. Systematic reviews of the literature are unable to establish definitive conclusions regarding the effectiveness of other adjunct therapies in dental caries prevention. CONCLUSIONS: Further research with elders requires improved study design with well designed multi-center trials. Considerations for new strategies for research of the effectiveness of therapies to reduce dental caries include the development and evaluation of combinations of therapeutic interventions and dental caries management by risk assessment.

Antibiotic concentrations in saliva: a systematic review of the literature, with clinical implications for the treatment of sialadenitis.

PURPOSE: The current recommendations for the treatment of bacterial salivary gland infections are mainly empirical. Therefore, an evidence-based literature review was conducted to identify antibiotics with favorable pharmacokinetics in saliva and to establish recommendations for the antibiotic treatment of sialadenitis. MATERIALS AND METHODS: The authors performed a systematic review of the pertinent literature published from 1985 to 2013. If the predefined inclusion criteria were met, the articles were screened for various variables: antibiotic type, mode of administration, type of examined saliva, peak salivary antibiotic concentrations, biochemical methodology, and minimal inhibitory concentrations of bacteria implicated in sialadenitis (Staphylococcus aureus, Viridans streptococci, various gram-negative strains, and anaerobes). RESULTS: The review included 18 studies. The systematic analysis of the reported results concurred that intravenously administered cephalosporins achieve the highest concentrations in saliva, followed by orally administered cephalosporins and fluoroquinolones. These concentrations exceed the minimal inhibitory concentrations of the bacteria of interest. Phenoxymethylpenicillin and tetracyclines are not secreted in the saliva at bactericidal levels. The antibiotic peak salivary levels depended on the type of saliva examined (parotid vs submandibular vs minor salivary gland) and the biochemical method of measurement (high-performance liquid chromatography vs bioassay). CONCLUSION: Cephalosporins and fluoroquinolones display superior pharmacokinetics in saliva and cover the spectrum of all bacteria implicated in sialadenitis. Within the limitations of this review, they can be recommended for the treatment of bacterial salivary gland infections.

Oral health delivery systems for older adults and people with disabilities.

This article describes new oral health care system models designed to meet the needs of a rapidly growing population of older adults and people with disabilities. These populations are not currently able to access traditional dental offices and clinics to the same degree that younger and much healthier population groups do. So new models proactively target specific community organizations where these high-risk underserved population groups live, work, go to school, or obtain other health or social services. Collaborative on-site and clinic-based teams establish "Virtual Dental Homes" that provide ongoing, year-round access to oral health services designed to prevent mouth infections, deliver evidence-based preventive care, and restore infected individuals to stable and sustainable oral health. These new delivery models are beginning to demonstrate better health care delivery, better health outcomes, and the potential to drive down total health care costs for older adults and people with disabilities.

A four-tier problem-solving scaffold to teach pain management in dental school.

Pain constitutes a major reason patients pursue dental treatment. This article presents a novel curriculum to provide dental students comprehensive training in the management of pain. The curriculum's four-tier scaffold combines traditional and problem-based learning to improve students' diagnostic, pharmacotherapeutic, and assessment skills to optimize decision making when treating pain. Tier 1 provides underpinning knowledge of pain mechanisms with traditional and contextualized instruction by integrating clinical correlations and studying worked cases that stimulate clinical thinking. Tier 2 develops critical decision making skills through self-directed learning and actively solving problem-based cases. Tier 3 exposes students to management approaches taken in allied health fields and cultivates interdisciplinary communication skills. Tier 4 provides a "knowledge and experience synthesis" by rotating students through community pain clinics to practice their assessment skills. This combined teaching approach aims to increase critical thinking and problem-solving skills to assist dental graduates in better management of pain throughout their careers. Dental curricula that have moved to comprehensive care/private practice models are well-suited for this educational approach. The goal of this article is to encourage dental schools to integrate pain management into their curricula, to develop pain management curriculum resources for dental students, and to provide leadership for change in pain management education.