Direct composite resin fillings versus amalgam fillings for permanent posterior teeth.

BACKGROUND: Traditionally, amalgam has been used for filling cavities in posterior teeth, and it continues to be the restorative material of choice in some low- and middle-income countries due to its effectiveness and relatively low cost. However, there are concerns over the use of amalgam restorations (fillings) with regard to mercury release in the body and the environmental impact of mercury disposal. Dental composite resin materials are an aesthetic alternative to amalgam, and their mechanical properties have developed sufficiently to make them suitable for restoring posterior teeth. Nevertheless, composite resin materials may have potential for toxicity to human health and the environment. The United Nations Environment Programme has established the Minamata Convention on Mercury, which is an international treaty that aims "to protect the [sic] human health and the environment from anthropogenic emissions and releases of mercury and mercury compounds". It entered into force in August 2017, and as of February 2021 had been ratified by 127 governments. Ratification involves committing to the adoption of at least two of nine proposed measures to phase down the use of mercury, including amalgam in dentistry. In light of this, we have updated a review originally published in 2014, expanding the scope of the review by undertaking an additional search for harms outcomes. Our review synthesises the results of studies that evaluate the long-term effectiveness and safety of amalgam versus composite resin restorations, and evaluates the level of certainty we can have in that evidence. OBJECTIVES: To examine the effects (i.e. efficacy and safety) of direct composite resin fillings versus amalgam fillings. SEARCH METHODS: An information specialist searched five bibliographic databases up to 16 February 2021 and used additional search methods to identify published, unpublished and ongoing studies SELECTION CRITERIA: To assess efficacy, we included randomised controlled trials (RCTs) comparing dental composite resin with amalgam restorations in permanent posterior teeth that assessed restoration failure or survival at follow-up of at least three years. To assess safety, we sought non-randomised studies in addition to RCTs that directly compared composite resin and amalgam restorative materials and measured toxicity, sensitivity, allergy, or injury. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. MAIN RESULTS: We included a total of eight studies in this updated review, all of which were RCTs. Two studies used a parallel-group design, and six used a split-mouth design. We judged all of the included studies to be at high risk of bias due to lack of blinding and issues related to unit of analysis. We identified one new trial since the previous version of this review (2014), as well as eight additional papers that assessed safety, all of which related to the two parallel-group studies that were already included in the review. For our primary meta-analyses, we combined data from the two parallel-group trials, which involved 1645 composite restorations and 1365 amalgam restorations in 921 children. We found low-certainty evidence that composite resin restorations had almost double the risk of failure compared to amalgam restorations (risk ratio (RR) 1.89, 95% confidence interval (CI) 1.52 to 2.35; P < 0.001), and were at much higher risk of secondary caries (RR 2.14, 95% CI 1.67 to 2.74; P < 0.001). We found low-certainty evidence that composite resin restorations were not more likely to result in restoration fracture (RR 0.87, 95% CI 0.46 to 1.64; P = 0.66). Six trials used a split-mouth design. We considered these studies separately, as their reliability was compromised due to poor reporting, unit of analysis errors, and variability in methods and findings. Subgroup analysis showed that the findings were consistent with the results of the parallel-group studies. Three trials investigated possible harms of dental restorations. Higher urinary mercury levels were reported amongst children with amalgam restorations in two trials, but the levels were lower than what is known to be toxic. Some differences between amalgam and composite resin groups were observed on certain measures of renal, neuropsychological, and psychosocial function, physical development, and postoperative sensitivity; however, no consistent or clinically important harms were found. We considered that the vast number of comparisons made false-positive results likely. There was no evidence of differences between the amalgam and composite resin groups in neurological symptoms, immune function, and urinary porphyrin excretion. The evidence is of very low certainty, with most harms outcomes reported in only one trial. AUTHORS' CONCLUSIONS: Low-certainty evidence suggests that composite resin restorations may have almost double the failure rate of amalgam restorations. The risk of restoration fracture does not seem to be higher with composite resin restorations, but there is a much higher risk of developing secondary caries. Very low-certainty evidence suggests that there may be no clinically important differences in the safety profile of amalgam compared with composite resin dental restorations. This review supports the utility of amalgam restorations, and the results may be particularly useful in parts of the world where amalgam is still the material of choice to restore posterior teeth with proximal caries. Of note, however, is that composite resin materials have undergone important improvements in the years since the trials informing the primary analyses for this review were conducted. The global phase-down of dental amalgam via the Minamata Convention on Mercury is an important consideration when deciding between amalgam and composite resin dental materials. The choice of which dental material to use will depend on shared decision-making between dental providers and patients in the clinic setting, and local directives and protocols.

Post-operative pain management in dental implant surgery: a systematic review and meta-analysis of randomized clinical trials.

PURPOSE: To evaluate the clinical efficacy of various analgesic medications in mitigating orofacial pain following dental implant surgery. MATERIALS AND METHODS: A systematic search was conducted to identify randomized controlled clinical trials (RCTs). The primary outcomes examined were post-operative pain (POP) and consumption of rescue analgesics following implant placement; secondary outcomes included adverse effects, post-operative inflammation, infection, swelling, bleeding, patient satisfaction, and quality of life. Random effects meta-analysis was conducted for risk ratios of dichotomous data. RESULTS: Nine RCTs fulfilled the eligibility criteria. Individual studies and meta-analysis of two studies indicated that nonsteroidal anti-inflammatory drugs (NSAIDs) significantly reduced POP and consumption of rescue analgesics after dental implant placement compared to placebo. Transdermal administration of NSAIDs may be superior to the oral route as it was similarly effective for POP control and resulted in fewer side effects. Glucocorticoids administered as primary analgesics or NSAID adjuvants resulted in comparable pain sensation compared to NSAIDs alone. Caffeine-containing analgesics were reported as acceptable and effective for the treatment of POP and swelling when compared to codeine adjuvants. With regard to analgesic dosing schedules, pain modulation may be most critical during the first 72 h following dental implant placement. Risk of bias assessment indicated an overall low risk of bias across the included trials. CONCLUSION: Within the limitations of this review, POP following implant surgery may be effectively treated with the short-term use of analgesic medications. However, given the heterogeneity in the available RCTs, there is insufficient evidence to recommend an analgesic regimen following dental implant surgery. CLINICAL RELEVANCE: Short-term use of analgesic medications may be sufficient for post-operative pain management in dental implant surgery. Ultimately, the clinician's analgesic prescription should be directed by a patient's medical history, in order to increase the success of pain management in a short period of time and decrease potential adverse effects. TRIAL REGISTRATION: CRD42018099324.

What is the societal economic cost of poor oral health among older adults in the United States? A scoping review.

OBJECTIVE: To assess the state of the literature in the United States quantifying the societal economic cost of poor oral health among older adults. BACKGROUND: Proponents of a Medicare dental benefit have argued that addressing the growing need for dental care among the US older adult population will decrease costs from systemic disease and other economic costs due to oral disease. However, it is unclear what the current economic burden of poor oral health among older adults is in the United States. METHODS: We conducted a scoping review examining the cost of poor oral health among older adults and identified cost components that were included in relevant studies. RESULTS: Other than oral cancer, no studies were found examining the economic costs of poor oral health among older adults (untreated tooth decay, gum disease, tooth loss and chronic disease/s). Only two studies examining the costs of oral cancer were found, but these studies did not assess the full economic cost of oral cancer from patient, insurer and societal perspectives. CONCLUSIONS: Future work is needed to assess the full economic burden of poor oral health among older adults in the United States, and should leverage novel linkages between medical claims data, dental claims data and oral health outcomes data.

Limited Evidence Suggests Metformin Might Be Beneficial to Reduce Head and Neck Cancer Risk and Increase Overall Survival, While Any Benefit With Antiinflammatory Drugs Is Inconsistent.

ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION: Protective effects of metformin, statins, and antiinflammatory drugs on head and neck cancer: A systematic review. Saka Herrán C, Jané-Salas E, Devesa AE, López-López J. Oral Oncol 2018;85:68-81. SOURCE OF FUNDING: None. TYPE OF DESIGN: Systematic review with meta-analysis.

One phase or two phase orthodontic treatment for Class II division 1 malocclusion ?

Data sources Numerous online databases were searched including:, the Cochrane Central Register of Controlled Trials, the Cochrane Library, MEDLINE Ovid and Embase Ovid). The US National Institutes of Health Ongoing Trials Registry (ClinicalTrials.gov) and the World Health Organization International Clinical Trials. No restrictions were placed on the language or date of publication when searching the electronic databases.Study selection The review included only randomised clinical trials of orthodontic treatments to correct prominent upper front teeth (Class II malocclusion) in children and adolescents. The review selected studies that compared early treatment in children (two-phase) with any type of orthodontic braces (removable, fixed, functional) or head-braces/headgear versus late (one-phase) treatment in adolescents with any type of orthodontic braces or head-braces/headgear, and studies that compared any type of orthodontic braces or head-braces/headgear versus no treatment or another type of orthodontic brace/treatment or appliance (where treatment started at a similar age in the intervention groups). The review excluded studies involving participants with craniofacial deformities/syndromes or a cleft lip or palate, and trials that recruited patients who had previously received surgical treatment for their Class II malocclusion.Data extraction and synthesis The review authors screened the search results, extracted data and assessed risk of bias independently, and used odds ratios (ORs) and 95% confidence intervals (CIs) for dichotomous outcomes (incisal trauma), and mean differences (MDs) and 95% CIs for continuous outcomes (overjet and ANB angle).Results Twenty-seven studies were included and analysed in the review. Out of the 27 trials , three trials (343 patients - low /moderate quality evidence ) compared early/ two stage orthodontic treatment with functional appliances versus late two phases orthodontic treatment assessing all changes in overjet, cephalometric changes (antero-posterior relationship of the mandible to the maxilla or ANB angle) and incisal trauma in the upper anterior teeth.Firstly the results showed a reduction in the overjet and ANB angle after phase one of early treatment in patients using functional appliances, before the other group had received any treatment; the results changed when both groups underwent treatment, resulting in a non-statistical difference between groups in final overjet (MD 0.21, 95% CI -0.10 to 0.51, P = 0.18; or ANB (MD -0.02, 95% CI -0.47 to 0.43).Incidence of new incisal trauma: the results favoured initial or early treatment with functional appliances. The odds of incisal trauma using early functional appliances were reduced compared to late treatment: OR 0.56 (95% CI 0.33 to 0.95). The incidence of front teeth trauma was 30% in the participants of the late treatment group/ one phase compared to 19% in the participants who received the early/two phase orthodontic treatment ( 332 patients - moderate quality evidence).Headgear versus late treatment: early (two-phase) treatment with headgear reduced roughly half the incidence of new front teeth trauma (OR 0.45, 95% CI 0.25 to 0.80) compared to the late treatment group . The use of headgear reduced overjet and ANB, however, when both groups finalised the treatment, there was no statistically significant difference between groups in overjet (MD -0.22, 95% CI -0.56 to 0.12; or ANB (MD -0.27°, 95% CI -0.80 to 0.26) (low quality evidence).Fixed functional appliances versus no treatment (low quality evidence): the analysis of seven trials that compared late treatment with functional appliances versus no treatment concluded that there was a reduction in final overjet with fixed functional appliances (MD -5.46 mm, 95% CI -6.63 to -4.28 ).There was no evidence of a difference in final ANB between fixed functional appliances and no treatment (MD -0.53, 95% CI -1.27 to -0.22 ).Removable functional appliances to reduce ANB compared to no treatment: the results ( low quality evidence) showing a MD of -2.37° (95% CI -3.01 to -1.74 ), favouring the functional appliances.Twin block appliance versus other appliances in adolescents: six studies found no difference in changes in overjet (0.08 mm, 95% CI -0.60 to 0.76) . The reduction in ANB favoured treatment with a twin block (-0.56°, 95% CI -0.96 to -0.16).Removable functional appliances versus fixed appliances: the data combination of three trials concluded that there is a reduction in overjet in favour of fixed appliances (0.74, 95% CI 0.15 to 1.33), and a reduction in ANB in favour of removable appliances (-1.04° , 95% CI -1.60 to -0.49).Conclusions Evidence classified as low to moderate quality suggests that providing early orthodontic treatment/two stages for children with prominent upper front teeth is more effective for reducing the incidence of upper front teeth trauma ( incisal trauma) than providing one course of orthodontic treatment in adolescence. However, it appears that there is no other benefit of providing early treatment when compared to late treatment. Low-quality evidence proposes that, compared to no treatment, late treatment in adolescence with functional appliances, is effective for reducing the prominence of upper front teeth.

A systematic review on incidental findings in cone beam computed tomography (CBCT) scans.

OBJECTIVES: Cone beam CT's use (CBCT) in dentistry is increasing. Incidental findings (IFs: discoveries unrelated to the original purpose of the scan), are frequently found as a result of a large field of view. The aim of the systematic review is to analyze present literature on IFs using CBCT. METHODS AND MATERIALS: The authors searched online databases of studies and assessed the prevalence of IFs among patients undergoing head and neck CBCT scans. STROBE criteria was used to evaluate the quality of the studies. RESULTS: The original search retrieved 509 abstracts of which only 10 articles met the inclusion criteria. The sample size varied between 90 and 1000 participants. The frequency of IFs of the selected articles were 24.6-94.3%. The most common non-threatening IFs were found in the airway, such as mucous retention cyst (55.1%) and sinusitis (41.7%). Other non-threatening IFs were soft tissue calcifications such as calcified stylohyloid ligament (26.7%), calcified pineal gland (19.2%), and tonsillolith (14.3%). Threatening IFs were rare findings (1.4%). Three articles reported incidental carotid artery calcifications with a prevalence of 5.7-11.6%. Pathological findings were not common between the articles, but still relevant (2.6%). The studies had a risk of bias varying from moderate to low. CONCLUSIONS: There is a high frequency of IFs, yet not all of them require immediate medical attention. The low prevalence of threatening IFs emphasizes that CBCT should not be considered a substitution for conventional radiographs, but when used, the scans should be evaluated by a maxillofacial radiologist.

One phase or two phases orthodontic treatment for Class II division 1 malocclusion?

Data sources Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 27 September 2017), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2017, Issue 8), MEDLINE Ovid (1946 to 27 September 2017), and Embase Ovid (1980 to 27 September 2017). The US National Institutes of Health Ongoing Trials Registry (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases.Study selection Randomised controlled trials of orthodontic treatments to correct prominent upper front teeth (Class II malocclusion) in children and adolescents. The review included trials that compared early treatment in children (two-phase) with any type of orthodontic braces (removable, fixed, functional) or head-braces versus late treatment in adolescents (one-phase) with any type of orthodontic braces or head-braces, and trials that compared any type of orthodontic braces or head-braces versus no treatment or another type of orthodontic brace or appliance (where treatment started at a similar age in the intervention groups). The review excluded trials involving participants with a cleft lip or palate, or other craniofacial deformity/syndrome, and trials that recruited patients who had previously received surgical treatment for their Class II malocclusion.Data extraction and synthesis Review authors screened the search results, extracted data and assessed risk of bias independently. They used odds ratios (ORs) and 95% confidence intervals (CIs) for dichotomous outcomes, and mean differences (MDs) and 95% CIs for continuous outcomes.Results From the 27 studies included in the review:Three trials compared early treatment with a functional appliance versus late treatment for overjet, ANB and incisal trauma. After phase one of early treatment (i.e. before the other group had received any intervention), there was a reduction in overjet and ANB reduction favouring treatment with a functional appliance; however, when both groups had completed treatment, there was no difference between groups in final overjet (MD 0.21, 95% CI -0.10 to 0.51, P = 0.18; 343 participants) (low-quality evidence) or ANB (MD -0.02, 95% CI -0.47 to 0.43; 347 participants) (moderate-quality evidence). Early treatment with functional appliances reduced the incidence of incisal trauma compared to late treatment (OR 0.56, 95% CI 0.33 to 0.95; 332 participants) (moderate-quality evidence). The difference in the incidence of incisal trauma was clinically important with 30% (51/171) of participants reporting new trauma in the late treatment group compared to only 19% (31/161) of participants who had received early treatment. Two trials compared early treatment using headgear versus late treatment. After phase one of early treatment, headgear had reduced overjet and ANB; however, when both groups had completed treatment, there was no evidence of a difference between groups in overjet (MD -0.22, 95% CI -0.56 to 0.12; 238 participants) (low-quality evidence) or ANB (MD -0.27, 95% CI -0.80 to 0.26; 231 participants) (low-quality evidence). Early (two-phase) treatment with headgear reduced the incidence of incisal trauma (OR 0.45, 95% CI 0.25 to 0.80; 237 participants) (low-quality evidence), with almost half the incidence of new incisal trauma (24/117) compared to the late treatment group (44/120). Seven trials compared late treatment with functional appliances versus no treatment. There was a reduction in final overjet with both fixed functional appliances (MD -5.46 mm, 95% CI -6.63 to -4.28; 2 trials, 61 participants) and removable functional appliances (MD -4.62, 95% CI -5.33 to -3.92; 3 trials, 122 participants) (low-quality evidence). There was no evidence of a difference in final ANB between fixed functional appliances and no treatment (MD -0.53°, 95% CI -1.27 to -0.22; 3 trials, 89 participants) (low quality evidence), but removable functional appliances seemed to reduce ANB compared to no treatment (MD -2.37°, 95% CI -3.01 to -1.74; 2 trials, 99 participants) (low-quality evidence). Six trials compared orthodontic treatment for adolescents with Twin Block versus other appliances and found no difference in overjet (0.08 mm, 95% CI -0.60 to 0.76; 4 trials, 259 participants) (low-quality evidence). The reduction in ANB favoured treatment with a Twin Block (-0.56°, 95% CI -0.96 to -0.16; 6 trials, 320 participants) (low-quality evidence). Three trials compared orthodontic treatment for adolescents with removable functional appliances versus fixed functional appliances and found a reduction in overjet in favour of fixed appliances (0.74, 95% CI 0.15 to 1.33; two trials, 154 participants) (low-quality evidence), and a reduction in ANB in favour of removable appliances (-1.04°, 95% CI -1.60 to -0.49; 3 trials, 185 participants) (low-quality evidence).Conclusions Evidence of low to moderate quality suggests that providing early orthodontic treatment for children with prominent upper front teeth is more effective for reducing the incidence of incisal trauma than providing one course of orthodontic treatment in adolescence. There appear to be no other advantages of providing early treatment when compared to late treatment. Low-quality evidence suggests that, compared to no treatment, late treatment in adolescence with functional appliances, is effective for reducing the prominence of upper front teeth.

Inconclusive evidence of treatment modalities for peri-implantitis.

Data sources Ovid Medline, Embase, EBM Review, Cochrane Central Register of Control Trials and the Cochrane Database of Systematic Reviews.Study selection Randomised controlled trials or prospective cohort studies published in English with ≥10 patients and ≥6 months follow-up (the longest follow-up period was chosen in longitudinal studies which were published more than once). Experimental animal or in vitro studies were excluded.Data extraction and synthesis Data on the primary outcome reduction in bleeding on probing (BOP) in implants treated surgically for peri-implantitis, and secondary outcomes pocket probing depth (PPD) and RBL (radiographic bone-loss) were extracted and meta-analysis conducted. Results Sixteen papers met the inclusion criteria. Four treatment modalities to supplement mechanical debridement were identified: (1) apically repositioned flap, (2) chemical surface decontamination, (3) implantoplasty and (4) bone augmentation. Inconsistent results were evident which were dependent on several treatment-independent factors. No clinical benefits were identified for the additional use of surface decontamination, while limited evidence demonstrated improvement of clinical and radiographic outcomes after implantoplasty. The effect of bone augmentation appeared limited to 'filling' radiographic defects. The meta-analysis was conducted using eight randomised clinical trials and two controlled prospective cohort studies. Meta-analysis demonstrated that implants treated with surface decontamination had SMD of -0.21 (95% CI: -1.70 to 1.27) for periodontal pocket reduction (PPD) reduction. Only one study reported the effect of implantoplasty on PPD, which shows a significant SMD of -3.33 (95% CI: -4.37 to -2.28 mm). Bone augmentation with grafting materials and the additional use of membrane resulted in SMD of 0.15 mm (95% CI: -0.55 to 0.84 mm) and 0.30 mm (95% CI: -0.31 to 0.91 mm), respectively. In terms of RBL changes, the use of surface decontamination methods resulted in SMD of 0.54 mm (95% CI: -0.20 to 1.28 mm). Implants treated with implantoplasty had SMD of -3.38 (95% CI: -.43 to -2.33 mm). The SMD for RBL changes after the use of bone augmentation was -1.05 (95% CI: -1.80 to -0.31 mm). However, the additional use of membrane had SMD of -0.16 (95% CI: -0.56 to 0.24 mm.Conclusions The outcomes of the currently available surgical interventions for peri-implantitis remain unpredictable. There is no reliable evidence to suggest which methods are the most effective. Further randomised controlled studies are needed to identify the best treatment methods.

Dental cavity liners for Class I and Class II resin-based composite restorations.

BACKGROUND: Resin-based composite (RBC) is currently accepted as a viable material for the restoration of caries for posterior permanent teeth requiring surgical treatment. Despite the fact that the thermal conductivity of the RBC restorative material closely approximates that of natural tooth structure, postoperative hypersensitivity is sometimes still an issue. Dental cavity liners have historically been used to protect the pulp from the toxic effects of some dental restorative materials and to prevent the pain of thermal conductivity by placing an insulating layer between restorative material and the remaining tooth structure. This is an update of the Cochrane Review first published in 2016. OBJECTIVES: The objective of this review was to assess the effects of using dental cavity liners in the placement of Class I and Class II resin-based composite posterior restorations in permanent teeth in children and adults. SEARCH METHODS: Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 12 November 2018), the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 10) in the Cochrane Library (searched 12 November 2018), MEDLINE Ovid (1946 to 12 November 2018), Embase Ovid (1980 to 12 November 2018) and LILACS BIREME Virtual Health Library (Latin American and Caribbean Health Science Information database; 1982 to 12 November 2018). We searched ClinicalTrials.gov and the World Health Organization International 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 randomized controlled trials assessing the effects of the use of liners under Class I and Class II posterior resin-based composite restorations in permanent teeth (in both adults and children). We included both parallel and split-mouth designs. DATA COLLECTION AND ANALYSIS: We utilized standard methodological procedures prescribed by Cochrane for data collection and analysis. Two review authors screened the search results and assessed the eligibility of studies for inclusion against the review inclusion criteria. We conducted risk of bias assessments and data extraction independently and in duplicate. Where information was unclear we contacted study authors for clarification. MAIN RESULTS: Eight studies, recruiting over 700 participants, compared the use of dental cavity liners to no liners for Class I and Class II resin-based composite restorations.Seven studies evaluated postoperative hypersensitivity measured by various methods. All studies were at unclear or high risk of bias. There was inconsistent evidence regarding postoperative hypersensitivity (either measured using cold response or patient-reported), with a benefit shown at some, but not all, time points (low-quality evidence).Four trials measured restoration longevity. Two of the studies were judged to be at high risk and two at unclear risk of bias. No difference in restoration failure rates were shown at 1 year follow-up, with no failures reported in either group for three of the four studies; the fourth study had a risk ratio (RR) 1.00 (95% confidence interval (CI) 0.07 to 15.00) (low-quality evidence). Three studies evaluated restoration longevity at 2 years follow-up and, again, no failures were shown in either group.No adverse events were reported in any of the included studies. AUTHORS' CONCLUSIONS: There is inconsistent, low-quality evidence regarding the difference in postoperative hypersensitivity subsequent to placing a dental cavity liner under Class I and Class II posterior resin-based composite restorations in permanent posterior teeth in adults or children 15 years or older. Furthermore, no evidence was found to demonstrate a difference in the longevity of restorations placed with or without dental cavity liners.

The Effect of Silver Diamine Fluoride in Preventing Caries in the Primary Dentition: A Systematic Review and Meta-Analysis.

OBJECTIVES: To investigate whether silver diamine fluoride (SDF) is effective in preventing new caries lesions in primary teeth when compared to placebo or active treatments. METHODS: Systematic review (CRD42016036963) of controlled clinical trials. Searches were performed in 9 electronic databases, 5 registers of ongoing trials, and reference lists of identified review articles. Two researchers carried out data extraction and quality appraisal independently. The primary outcome was the difference in caries increment (decayed, missing, and filled surfaces or teeth - dmfs or dmft) between SDF and control groups. These differences were pooled as weighted mean differences (WMD) and prevented fractions (PF). RESULTS: Searches yielded 2,366 unique records; 6 reports of 4 trials that randomized 1,118 and analyzed 915 participants were included. Two trials compared SDF to no treatment, 1 compared SDF to placebo and sodium fluoride varnish (FV), and 1 compared SDF to high-viscosity glass ionomer cement (GIC). All studies had at least 1 domain with unclear or high risk of bias. After 24 months of follow-up, in comparison to placebo, no treatment, and FV, SDF applications significantly reduced the development of new dentin caries lesions (placebo or no treatment: WMD = -1.15, PF = 77.5%; FV: WMD = -0.43, PF = 54.0%). GIC was more effective than SDF after 12 months of follow-up but the difference between them was not statistically significant (WMD, dmft: 0.34, PF: -6.09%). CONCLUSION: When applied to caries lesions in primary teeth, SDF compared to no treatment, placebo or FV appears to effectively prevent dental caries in the entire dentition. However, trials specifically designed to assess this outcome are needed.

Anodised or turned dental implants?

Data sourcesAn electronic search without time or language restrictions was undertaken using several databases: PubMed/Medline, Web of Science and the Cochrane Oral Health Group Trials Register and ongoing clinical trials. Manual searches were performed in dental implant related journals and reference lists of identified studies, and relevant reviews were scanned for possible additional studies.Study selectionEligibility criteria included human clinical studies, either randomised or not, comparing implant failure rates, MBL and/or post-operative infection in any group of patients receiving turned (machined) and anodised-surface (TiUnite) implants, both from the same implant manufacturer.Data extraction and synthesisThe titles and abstracts of all reports identified through the electronic searches were read independently by the three authors. For studies appearing to meet the inclusion criteria, or for which there were insufficient data in the title and abstract to make a clear decision, the full report was obtained. Disagreements were resolved by discussion between the authors. Quality assessment of the studies was executed according to the Newcastle-Ottawa scale (NOS), which is a quality assessment tool used when observational studies are also included in systematic reviews.ResultsThirty-eight publications were included. The results suggest a risk ratio =2.82(95%CI, 1.95 - 4.06, P < 0.00001) for failure of turned implants when compared to anodised-surface implants. Sensitivity analyses showed similar results when only the studies inserting implants in maxillae or mandibles were pooled. There were no statistically significant effects of turned implants on the MBL (mean difference [MD]=0.02, (95%CI, 0.16 - 0.20; P = 0 82) in comparison to anodised implants. The results of a meta-regression considering the follow-up period as a covariate suggested an increase of the MD with the increase in the follow-up time (MD increase 0.012 mm year 1), however, without a statistical significance (P = 0.813). Due to lack of satisfactory information, meta-analysis for the outcome 'post-operative infection' was not performed.ConclusionsWithin the limitations of the existing investigations, the present study suggests that turned implants have a statistically higher probability to fail than anodised-surface implants, regardless of whether the implants were placed in maxilla or mandible. There were no statistically significant effects of turned implants on the MBL when compared with anodised implants. A comparison of post-operative infection between the implant types was not possible, due to lack of sufficient information. The reliability and validity of the data collected, the limitations of the quality assessment tool and the potential for biases and confounding factors are some of the shortcomings of the present study. The results have to be interpreted with caution due to the presence of several confounding factors in the included studies.

Extraction or non-extraction treatment for Class II division 2 malocclusion?

Data sourcesThe following databases were searched: Cochrane Oral Health Trial Register, Cochrane central register for controlled trials, Medline Ovid and Embase Ovid. The following were searched for ongoing trials: US National Institutes of Health Trials Register and World Health Organization International Clinical Trials Registry Platform. No language, publication year or publication status restrictions were imposed.Study selectionRandomised controlled trials (RCTs) and controlled clinical trials (CCTs) of orthodontic treatment to correct deep bite and retroclined upper front teeth were included. Two independent reviewers scanned and reviewed all papers and abstracts to be included. When necessary, primary authors were contacted, and additional or missing information was obtained. Trials which recruited participants 16 years or less without surgical intervention to correct their class II malocclusion were to be included. Trials that included participants with cleft lip/palate or any other craniofacial syndrome were excluded.Data extraction and synthesisIf data were to be selected, all data would have been complied into a customised data collection form. The following were to be included in the analysis; year of publication, country of origin, setting and source of study funding and details on the type of interventions including appliance type. Additionally, details of the participants including demographic characteristics, criteria for inclusion and exclusion and sample size by study group were to be taken into account. Details of the outcomes reported, including method of assessment, time intervals, details of withdrawals by study group, details of outcomes, including measures and timepoints were also supposed to be compiled for completeness. The risk of bias was planned to be reviewed. Measurements of treatment effect including risk ratios and numbers needed to treat would have been included. A 95% confidence interval and assessment of heterogeneity were to be explored. Data synthesis was planned to follow the Cochrane statistical guidelines using Review Manager Software.ResultsOne thousand three hundred and forty-four records were identified through database searching and one extra article was identified through other sources. Eight hundred and fifty-seven records were isolated after duplicates were removed. All records were rejected. No articles were selected for inclusion. No RCTs or CCTs were found assessing orthodontic treatment without the removal of permanent teeth versus treatment with extraction of permanent teeth versus no treatment at all. Consequently, it is impossible to derive any evidence-based support for clinicians for the treatment of class II division 2 malocclusion in children.ConclusionsThere is no evidence from clinical trials to recommend or discourage any type of orthodontic treatment to correct Class II division 2 malocclusion in children. This situation seems unlikely to change as trials to evaluate the best management of Class II division 2 malocclusion are challenging to design and conduct due to low prevalence, difficulties with recruitment and ethical issues with randomisation.

Calidad y control en las publicaciones / Quality and control in publications

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Impact of asepsis technique on implant success. A review.

Asepsis is described as a state free from microorganisms. In medicine, an aseptic environment is necessary and expected to avoid the spread of infection through contact between persons, sprays and splashes, inhalation, and sharps. Most dental procedures are performed in a "clean "environment with the common use of personal protective equipment (PPE) such as disposable gloves, masks and protective eyewear with disinfection of surfaces and sterilization of instruments. For surgical procedure such as the insertion of endosseous implants, the recommendations are not clear. The use of antimicrobials and antibiotics before and after the procedure remains a controversial issue The purpose of this literature review is to evaluate the current evidence as to what is generally expected and widely accepted in the use of aseptic techniques for the surgical placement of endosseous implants, and the impact on implant survival and overall success.

Is osteoporosis a risk factor for implant survival or failure?

Data sourcesAn electronic search was performed in PubMed, Web of Science and the Cochrane Library and SciELO databases up to September 2016. References of included studies were also searched. English language restriction was applied.Study selectionClinical monitoring studies with at least six months of follow-up, including retrospective studies, prospective studies, and controlled and randomised clinical trials. Clinical case studies were excluded from the sample and only studies with a minimum of five patients were considered. Adults with osseointegrated implants were considered for these studies. Exclusion criteria encompassed studies performed in vitro, animal studies, non-controlled clinical cases, studies with incomplete data or those unsuitable for data collection.Data extraction and synthesisFour reviewers were involved in the research and screening process and disagreements were resolved by discussion. The quality of the studies was analysed using the bias scale from the Australian National Health and Medical Research Council (NHMRC). Data extracted from the studies included, when available: author, year of publication, study country of origin, number of patients, number of implants and sites, implant type, implant length and diameter, oral rehabilitation installation time, peri-implant bone loss rate, survival rate of implants in each situation analysed, follow-up time of each study, study type and drugs administered for the treatment of osteoporosis. For binary outcomes (implant failure) the estimate of the intervention effect was expressed in the form of a relative risk (RR) with the confidence interval (CI) of 95%. For continuous outcomes (marginal bone loss) the average and standard deviation (SD) were used to calculate the standardised mean difference with a 95% CI. A statistical test was used to express the heterogeneity among the studies. Publication bias was explored as well.ResultsA total of 15 observational studies were included in the review. The total number of patients involved was 8859 (29,798 implants) and the average age was 63.03 years.The follow-up period ranged from 0.75 to 22 years with a mean of 5.85 years. The smallest diameter used was 3.3 mm and the shortest implant length was 7 mm.The relative risk (RR) of implant failure and mean marginal bone loss were analysed within a 95% confidence interval (CI). The main outcome of the meta-analysis indicated that there was no difference in implant survival rate between patients with and without osteoporosis, either at the implant level (RR 1.39, 95% CI 0.93-2.08; P = 0.11) or at the patient level (RR 0.98, 95% CI 0.50-1.89; P = 0.94). However, the meta-analysis for the secondary outcome revealed a significant difference in marginal bone loss around implants between patients with and without osteoporosis (0.18 mm, 95% CI 0.05-0.30, P = 0.005). Data heterogeneity was low. An increase in peri-implant bone loss was observed in the osteoporosis group.ConclusionsThe implant survival rate in bone tissue with osteoporosis was similar to that of the control group at the implant level (P = 0.11) and at the patient level (P = 0.94). In conclusion, implants placed in patients with systemic osteoporosis did not present higher failure rates than those placed in patients without osteoporosis.

Taste disturbances - are there any effective treatments?

Data sourcesSeveral electronic databases were searched such as Cochrane Oral Health's Trials, Cochrane Library, Medline Ovid, CINAHL EBSCO and AMED Ovid and ongoing registered clinical trials in clinicaltrials.gov and in the World Health Organization International Clinical Trials Registry Platform. No restriction was placed on language and date of publication.Study selectionThe authors included randomised clinical trials (RCTs) and cross-over trials comparing any pharmacological intervention or any non-pharmacological agent with a control intervention.Data extraction and synthesisTwo pairs of review authors independently and in duplicate assessed the quality of trials and extracted data.ResultsThe review included ten trials (581 participants). Nine were included in the quantitative analysis. Three trials were assessed as having a low risk of bias, four at high risk of boas and three were assessed as unclear risk of bias. The studies included in the review were studies evaluating patients with taste disorders either idiopathic or resulting from zinc deficiency or chronic renal failure.Nine trials compared zinc supplements to placebo for patients with taste disorders. The participants in two trials were children and adolescents with respective mean ages of ten and 11.2 years and the other seven trials had adult participants. Out of these nine, two trials of very low quality assessed the patient-reported outcome for improvement in taste acuity using zinc supplements (risk ratio (RR) 1.40, 95% confidence interval (CI) 0.94 to 2.09.The meta-analyses of three trials classified as very low-quality evidence for taste acuity improvement in idiopathic and zinc-deficient taste disorder patients resulted in a standardised mean difference (SMD) = 0.44, (95% CI 0.23 to 0.65); 366 participants.One cross-over trial using the first half of the results for taste detection (mean difference (MD) 2.50, 95% CI 0.93 to 4.07; 14 participants, very low-quality evidence), and taste recognition (MD 3.00, 95% CI 0.66 to 5.34; 14 participants, very low-quality evidence). The authors performed a meta-analysis for taste acuity improvement using objective outcome (dichotomous data) in idiopathic and zinc-deficient taste disorder patients (RR 1.42, 95% CI 1.09 to 1.84; 292 participants, two trials, very low-quality evidence). Out of the nine trials using zinc supplementation, four reported adverse events like eczema, nausea, abdominal pain, diarrhoea, constipation, decrease in blood iron, increase in blood alkaline phosphatase and minor increase in blood triglycerides.One trial tested taste discrimination using acupuncture (MD 2.80, 95% CI -1.18 to 6.78; 37 participants, very low-quality evidence).No adverse events were reported in the acupuncture trial.ConclusionsThe authors found very low-quality evidence that was insufficient to conclude on the role of zinc supplements to improve taste acuity reported by patients and very low-quality evidence that zinc supplements improve taste acuity in patients with zinc deficiency/idiopathic taste disorders. They could not find any evidence to conclude the role of zinc supplements for improving taste discrimination, or any evidence addressing health-related quality of life due to taste disorders.Very low-quality evidence was found that is not sufficient to conclude on the role of acupuncture for improving taste discrimination in cases of idiopathic dysgeusia (distortion of taste) and hypogeusia (reduced ability to taste).The authors were unable to draw any conclusions regarding the superiority of zinc supplements or acupuncture as none of the trials compared these interventions.

Are fibre posts associated with the occurrence of prosthetic complications?

Data sourcesThe Pubmed, Evidence-Based Dentistry, BMJ Clinical Evidence, EmbaseDynamed, and www.opengrey.eu databases and manual search of reference lists.Study selectionRandomised clinical trials (RCTs) were accepted if they had: participants with no periodontal disease and teeth restored with SCs or FDPs and compared fibre posts and other prosthetic systems and evaluated the prosthetic complications with a minimum observational period of 36 months.Data extraction and synthesisTitles and abstracts were evaluated independently by two reviewers, any disagreement was discussed with a third reviewer. The agreement for the two reviewers was 97%. The quality and the risk of bias of the studies included was assessed following the Cochrane Handbook considering the domains of randomisation, sample size, inclusion and exclusion criteria, follow-up achieved, blinding, withdrawing and groups' compatibility for quality assessment, and for the risk of bias the domains evaluated were allocation concealment, blinding of outcome assessor and follow-up.ResultsThe database search yielded 4,230 records; after duplications removal, 3,670 records were reviewed independently by the authors, and four articles were chosen to include in the systematic review.The most frequently reported failures in the available studies were as follows: fibre post debonding, loss of retention of single crowns and marginal gaps. Less frequently, chippings and fractures were recorded in SCs. No studies about complications related to FDPs were found.The failure rate ranged from 0 to 28.2%.ConclusionsA correlation between the failure rates of fibre posts and the type of prosthetic restoration (SCs or FDPs ) cannot be found. Further RCTs are required to achieve evidence-based conclusions, particularly about the use of fibre posts with FDPs.

Single dose oral prednisolone and post-operative endodontic pain.

DesignA randomised, single centre, double blind placebo controlled clinical trial involving 400 patients.InterventionThe inclusion criteria comprised systemically healthy patients between the ages of 18 and 35 years having mandibular molars with symptomatic irreversible pulpitis, radiographically normal periapical area and no pain on biting or percussion. The study was approved by the Institutional Review Board of Ethics Committee at the School of Dentistry, Cairo University, Egypt. Patients were recruited from the outpatient clinic of the Department of Endodontics.The independent Centre for Evidence Based Dentistry performed sequence generation and allocation concealment. For allocation concealment, two tablets of each medication were placed in sequentially numbered, opaque, sealed containers. Participants and operators were unaware of the assigned group for the duration of the study. Post-graduate students were calibrated to act as operators and supervisors from the department of endodontics evaluated their clinical performance.The participants received 40 mg of prednisolone or placebo tablets 30 minutes before single visit root canal treatment. Patients recorded the pain level 6, 12 and 24 hours after treatment on a 100mm visual analogue scale. All patients received a sham capsule to take if needed as a postoperative analgesic. If pain persisted an analgesic was prescribed.Outcome measureThe primary outcome was the incidence of postoperative pain at three points; 6, 12 and 24 hrs. The secondary outcomes were pain intensity and the incidence of analgesic consumption. The relative risk reduction (RRR) and the number needed-to-treat (NNT) and their 95% confidence intervals (CI) were used to represent the risk of pain incidence.ResultsOf the 670 patients assessed for eligibility, 400 were included in the study. Only two patients of the 400 were lost to follow-up with 398 patients (prednisolone group = 198; control group = 200) being included in the analysis; 259 were women and 141 men. The mean age was 29.45 -/+ 3.7 years in the prednisolone group and 28.97 -/+3.61 years in the control group. There was no significant difference for mean age (P = 0.164), gender distribution P = 0.123) or tooth type (P = 0.56) between the two groups. The relative risk reduction in pain incidence was 20.31% (95% CI: 12.03%, 27.82%) at six hours, 23.39% (95% CI: 14.75%, 31.16%) at 12 hours and 28.85% (95% CI: 18.08%, 38.20%) at 24 hours. Prednisolone had significantly less post-obturation pain intensity compared to placebo at 6, 12 and 24 hours (P < 0.001). The relative risk reduction in sham-capsule intake was 54% (95% CI: 38%, 66%) and in analgesic intake was 55% (95% CI: 3%, 79%). No adverse effects were recorded. The NNT (number needed to treat) was five (95% CI: 4, 9) at six hours, five (95% CI: 4, 8) at 12 hours and four at 24 hours (95% CI: 3, 7).ConclusionsPreoperative oral administration of a single dose of 40 mg prednisolone was beneficial for the control of postoperative pain up to 24hrs after single visit root canal treatment in patients with symptomatic irreversible pulpitis. The incidence of postoperative pain level and the need for postoperative analgesic intake decreased. The non-invasive route and minimal possible adverse events results in a favourable risk benefit-balance.

Insufficient evidence for interventions to prevent dry mouth and salivary gland dysfunction post head and neck radiotherapy.

Data sourcesCochrane Oral Health's Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), Medline, Embase, CINAHL, EBSCO (Cumulative Index to Nursing and Allied Health Literature, LILACS, BIREME, Virtual Health Library (Latin American and Caribbean Health Science Information database), Zetoc Conference Proceedings, the US National Institutes of Health Ongoing Trials Register, (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases.Study selectionThe review included randomised controlled trials, irrespective of their language of publication or publication status. Participants could be outpatients or inpatients. The review included trials comparing any pharmacological agent regimen, prescribed prophylactically for salivary gland dysfunction prior to or during radiotherapy, with placebo, no intervention or an alternative pharmacological intervention. Comparisons of radiation techniques were excluded.Data extraction and synthesisStandard Cochrane methodological processes were followed.ResultsThirty-nine studies that randomised 3520 participants were included; the number of participants analysed varied by outcome and time point. The studies were ordered into 14 separate comparisons with meta-analysis only being possible in three of those. We found low quality evidence to show that amifostine, when compared to a placebo or no treatment control, might reduce the risk of moderate to severe xerostomia (grade 2 or higher on a 0 to 4 scale) at the end of radiotherapy (risk ratio (RR) 0.35, 95% confidence interval (CI) 0.19 to 0.67; P = 0.001, three studies, 119 participants), and up to three months after radiotherapy (RR 0.66, 95% CI 0.48 to 0.92; P = 0.01, five studies, 687 participants), but there is insufficient evidence that the effect is sustained up to 12 months after radiotherapy (RR 0.70, 95% CI 0.40 to 1.23; P = 0.21, seven studies, 682 participants). We found very low quality evidence that amifostine increased unstimulated salivary flow rate up to 12 months after radiotherapy, both in terms of mg of saliva per five minutes (mean difference (MD) 0.32, 95% CI 0.09 to 0.55; P = 0.006, one study, 27 participants), and incidence of producing greater than 0.1 g of saliva over five minutes (RR 1.45, 95%CI 1.13 to 1.86; P = 0.004, one study, 175 participants).However, there was insufficient evidence to show a difference when looking at stimulated salivary flow rates. There was insufficient (very low quality) evidence to show that amifostine compromised the effects of cancer treatment when looking at survival measures. There was some very low quality evidence of a small benefit for amifostine in terms of quality of life (ten-point scale) at 12 months after radiotherapy (MD 0.70, 95% CI 0.20 to 1.20; P = 0.006, one study, 180 participants), but insufficient evidence at the end of and up to three-month post radiotherapy. A further study showed no evidence of a difference at 6, 12, 18 and 24-month post radiotherapy.There was low quality evidence that amifostine is associated with increases in: vomiting (RR 4.90, 95% CI 2.87 to 8.38; P < 0.00001, five studies, 601 participants); hypotension (RR 9.20, 95% CI 2.84 to 29.83; P = 0.0002, three studies, 376 participants); nausea (RR 2.60, 95% CI 1.81 to 3.74; P < 0.00001, four studies, 556 participants); and allergic response (RR 7.51, 95% CI 1.40 to 40.39; P = 0.02, three studies, 524 participants).The authors founded insufficient evidence (that was of very low quality) to determine whether or not pilocarpine performed better or worse than a placebo or no treatment control for the outcomes: xerostomia, salivary flow rate, survival and quality of life. There was some low quality evidence that pilocarpine was associated with an increase in sweating (RR 2.98, 95% CI 1.43 to 6.22; P = 0.004, five studies, 389 participants).The authors found insufficient evidence to determine whether or not palifermin performed better or worse than placebo for: xerostomia (low quality); survival (moderate quality); and any adverse effects. There was also insufficient evidence to determine the effects of the following interventions: biperiden plus pilocarpine, Chinese medicines, bethanechol, artificial saliva, selenium, antiseptic mouthrinse, antimicrobial lozenge, polaprezinc, azulene rinse and Venalot Depot (coumarin plus troxerutin).ConclusionsThere is some low quality evidence to suggest that amifostine prevents the feeling of dry mouth in people receiving radiotherapy to the head and neck (with or without chemotherapy) in the short- (end of radiotherapy) to medium-term (three-month post radiotherapy). However, it is less clear whether or not this effect is sustained to 12-month post radiotherapy. The benefits of amifostine should be weighed against its high cost and side effects. There was insufficient evidence to show that any other intervention is beneficial.