Which is the most suitable local anaesthetic when inferior nerve blocks are used for impacted mandibular third molar extraction? A network meta-analysis.

The aim of this study was to compare the efficacy and safety of the different local anaesthetic agents for the extraction of impacted lower third molars. A network meta-analysis was performed of all published reports of randomized controlled clinical trials assessing efficacy (anaesthetic success and absence of need for supplementary anaesthesia during the surgical procedure) and/or safety (number of adverse events) of anaesthetic agents. Three electronic databases were searched, from their earliest records up to April 2019. Additionally, the grey literature was searched to identify further potential candidates for inclusion. Anaesthesia had to be delivered by an inferior alveolar nerve block, complemented with infiltration anaesthesia of the buccal nerve. The quality of the studies was assessed using the Cochrane Collaboration tool. This study included a total of 21 trials (2021 molars) assessing the efficacy and 19 trials (1977 molars) assessing the safety of 11 anaesthetic solutions. Seven of the studies included were considered to have a high risk of bias. The most effective local anaesthetic for the extraction of impacted mandibular third molars appeared to be 4% articaine, with significant differences when compared with 2% lidocaine, 0.5% bupivacaine, and 1% ropivacaine. Lidocaine is the safest local anaesthetic, although all investigated solutions can be used safely.

Distal caries of the second molar in the presence of a mandibular third molar - a prevention protocol.

Objectives The objectives of the prospective study were to establish the prevalence of distal caries (DC) in the mandibular second molar and to assess the outcomes of these diseased teeth in our population. Further aims were to identify associated risk factors and to design a protocol for prevention.Methods Clinical and radiographic data from 210 consecutive patients were ascertained over a three-month period. The sample population included all patients who had been referred to a hospital oral surgery department for a lower wisdom tooth assessment.Results A total of 224 mandibular third molars were included and assessed. The prevalence of caries affecting the distal aspect of the second molar was 38% (n = 85) in this population. In 18% of patients there was evidence of early enamel caries. Fifty-eight percent of caries was managed with restorative treatment but 11% of patients required second molar extraction and 13% of patients required the removal of the second and third molars. The prevalence of distal caries was significantly higher in patients with partially erupted wisdom teeth positioned below the amelocemental junction (P <0.05) of the adjacent second molar and in patients who presented with mesioangular impactions (P <0.001). However there was no difference in dental health when comparing this group to the remaining study population (P = 0.354). The Pearson chi-square test and Pearson correlation coefficient were used to verify the association between the tested variables.Conclusion This study demonstrates that the eruption status, type of angulation and the nature of tooth contact between both molars are useful disease predictors which can be used to indicate the likelihood of a caries process occurring on the distal aspect of the second mandibular molar. If patients' third molar teeth are not removed then consideration needs to be given to prevention and regular monitoring.

Dexketoprofen/tramadol: randomised double-blind trial and confirmation of empirical theory of combination analgesics in acute pain.

BACKGROUND: Combination analgesics are effective in acute pain, and a theoretical framework predicts efficacy for combinations. The combination of dexketoprofen and tramadol is untested, but predicted to be highly effective. METHODS: This was a randomised, double-blind, double-dummy, parallel-group, placebo-controlled, single-dose trial in patients with moderate or severe pain following third molar extraction. There were ten treatment arms, including dexketoprofen trometamol (12.5 mg and 25 mg) and tramadol hydrochloride (37.5 mg and 75 mg), given as four different fixed combinations and single components, with ibuprofen 400 mg as active control as well as a placebo control. The study objective was to evaluate the superior analgesic efficacy and safety of each combination and each single agent versus placebo. The primary outcome was the proportion of patients with at least 50 % max TOTPAR over six hours. RESULTS: 606 patients were randomised and provided at least one post-dose assessment. All combinations were significantly better than placebo. The highest percentage of responders (72%) was achieved in the dexketoprofen trometamol 25 mg plus tramadol hydrochloride 75 mg group (NNT 1.6, 95% confidence interval 1.3 to 2.1). Addition of tramadol to dexketoprofen resulted in greater peak pain relief and greater pain relief over the longer term, particularly at times longer than six hours (median duration of 8.1 h). Adverse events were unremarkable. CONCLUSIONS: Dexketoprofen trometamol 25 mg combined with tramadol hydrochloride 75 mg provided good analgesia with rapid onset and long duration in a model of moderate to severe pain. The results of the dose finding study are consistent with pre-trial calculations based on empirical formulae. TRIAL REGISTRATION: EudraCT (2010-022798-32); Clinicaltrials.gov (NCT01307020).

Current UK dental sedation practice and the 'National Institute for Health and Care Excellence' (NICE) guideline 112: sedation in children and young people.

AIM: Describe current dental sedation practice for under 19-year-olds in the UK and compare it with the recommendations of NICE guidance 112. METHOD: Members of the Society for the Advancement of Anaesthesia in Dentistry and members of the Dental Sedation Teachers Group were invited to participate in an online survey. RESULTS: Two hundred and sixty-six dentists and doctors completed the survey. Eighty-two percent were operator and sedationist (operator-sedationist). Ninety-five percent provided written information and 94% obtained written consent. Eighty-four percent kept a written or electronic sedation record. Eighty-six percent complied with life support training expectations. Eighty-six percent had immediate access to resuscitation equipment. Sixty-seven percent of sedationists reported that treatment could not be completed under sedation for <10% of cases during the previous year. When sedation was unsuccessful, 61% said they would schedule general anaesthesia and 54.5% would schedule advanced sedation care. Forty-nine percent believed that a dentist was an appropriate person to provide advanced sedation for 12-18 years. Only 24% thought a dentist should provide advanced sedation for children<12 years, with 75% preferring an anaesthetist. The appropriate setting for advanced sedation was thought to be primary care by 33% and secondary care by 68%. CONCLUSIONS: We found good agreement between the current practice of sedation and the recommendations of the NICE guidance 112.

The implications of substance misuse for intravenous conscious sedation practice.

Substance misuse is a major health concern in the United Kingdom, as the consequences for individuals are significant and may include multisystem organ damage. It is important for the dentist to know which patients are misusing substances as some pharmacological agents routinely used in dental practice may be contraindicated. The dentist should be aware of the range of clinical presentations that may arise from substance misuse and when suspected, a thorough drug history must be obtained. Patients may require special consideration and further investigations when planning elective procedures, particularly under intravenous conscious sedation. Therefore, management within a specialist centre and liaison with other health professionals may be indicated to ensure treatment is provided safely.

Ibuprofen and/or paracetamol (acetaminophen) for pain relief after surgical removal of lower wisdom teeth, a Cochrane systematic review.

This paper compares the beneficial and harmful effects of paracetamol, ibuprofen and the novel combination of both in a single tablet for pain relief following the surgical removal of lower wisdom teeth. In this systematic review only randomised controlled double-blinded clinical trials were included. We calculated the proportion of patients with at least 50% pain relief at 2 and 6 hours post dosing, along with the proportion of participants using rescue medication at 6 and 8 hours. Adverse events were also analysed. Data was meta-analysed where possible. Seven studies were included with a total of 2,241 participants enrolled. Ibuprofen 400 mg is superior to 1,000 mg paracetamol with a risk ratio for at least 50% pain relief at 6 hours of 1.47 (95% confidence interval [CI] 1.28 to 1.69). For the combined drug, the risk ratio for at least 50% maximum pain relief over 6 hours is 1.77 (95% CI 1.32 to 2.39) based on total pain relief (TOTPAR) data. There is high quality evidence that ibuprofen is superior to paracetamol. The novel combination drug shows encouraging results when compared to the single drugs (based on two trials).

Barriers to the use of morphine for the management of severe postoperative pain - a before and after study.

AIM: To reduce the number of patients experiencing severe postoperative pain by prescribing 10 mg Morphine either as oral solution or by IM injection as an alternative to Tramadol Hydrochloride in an analgesic protocol. MATERIALS AND METHODS: Patients who received in-patient oral and maxillofacial surgery under general anaesthesia were included. Complex intervention analgesic protocols were developed including staff education, patient educations and analgesic protocols. 80 patients were treated under the original protocol (tramadol hydrochloride for pain unmanaged by other drugs in protocol) over 4 months. 75 patients were treated under the second protocol (oral or intravenous morphine for pain unmanaged by other drugs in protocol). Patient perceptions to their pain management were then assessed. RESULTS: Proportion of patients reporting 'no pain' increased from 5% of 80 patients to 28% of 75 patients (p < 0.001). Report of severe pain reduced from 37% to 31% and not significant. Pain duration reduced from 18% to 12% for 75-100% time from surgery to discharge and not significant. Staff used protocols for 96% patients. Nurses provided patient information leaflets for 85%-80% patients. Nearly all patients (96% and 95%) reported overall satisfaction with their pain management. CONCLUSIONS: The use of morphine given orally or my IM injection rather than tramadol was associated with a significant increase in the number of patients reporting 'no pain'. However the number of patients experiencing severe pain was not significantly reduced. Despite this, most patients reported high levels of satisfaction which suggested that satisfaction questionnaires should not be used in isolation. Most patients received morphine orally rather than by IM injection but the oral dose may not have been high enough in this study.

NICE or not so NICE?

This article provides an opinion on the NHS NICE guidance on wisdom tooth removal introduced in 2000. Guidelines should support clinical decision-making by providing recommendations based on sound evidence but the wisdom tooth guidelines were published without any research evidence. General dentists and oral surgeons in England and Wales are under pressure to comply with this guidance but what have been the implications for patient care? There is growing evidence that patients have not been best served, with significant numbers developing caries in an adjacent tooth before consideration of wisdom tooth assessment.

Estimating the need for dental sedation. 4. Using IOSN as a referral tool.

OBJECTIVE: In this article we report on the use of the IOSN as a referral tool in primary care and the need for sedation in the referred patient population (as determined by the IOSN score). SETTING: Four centres in the North West of England (primary care) accepting referrals for treatment with the aid of sedation participated in this study. DESIGN: A service evaluation. SUBJECTS (MATERIALS) AND METHODS: The four were provided with IOSN referral forms, operator and patient questionnaires. The centres distributed IOSN forms to referrers as a means of recommending patients for sedation. All patients receiving treatment under sedation (having been referred for treatment through the IOSN form) were asked to complete the patient questionnaire. The individual operator who undertook the treatment under sedation was asked to complete the operator questionnaire. Data were entered into SPSS and the IOSN score noted. Statistical analyses of the data utilised descriptives and comparisons between groups using the Chi Squared test. RESULTS: Seventy-eight percent of the patients (n = 140) in this study were receiving treatment with sedation appropriately according to the principals of the IOSN. Patients deemed by the IOSN tool to have a low need for sedation were less likely to cancel their appointment if sedation had not been given. The majority of patients were female (70%) and the majority of operators and patients reported the IOSN forms acceptable for use. CONCLUSIONS: This study provides support for using the IOSN as a tool for organising sedation referral. The majority of operators and patients reported the IOSN forms acceptable for use.

Estimating the need for dental sedation. 1. The Indicator of Sedation Need (IOSN) - a novel assessment tool.

While the control of pain and anxiety is fundamental to the practice of dentistry, the use of conscious sedation in dentistry is very variable among dentists. The need for conscious sedation could be considered by assessing and ranking a combination of information on patient anxiety, medical history and the complexity of the anticipated clinical treatment. By undertaking this systemtic assessment an indication of sedation need may be developed which would act as an aide to decision making and, potentially, referral management. Such a tool could also be used by commissioners who need to identify patients who need conscious sedation for dental treatment in order to plan, commission and deliver appropriate sedation services.

Estimating the need for dental sedation. 2. Using IOSN as a health needs assessment tool.

AIM: This service evaluation assessed the need for sedation in a population of dental attenders (n = 607) in the North West of England. METHODS: Using the novel IOSN tool, three clinical domains of sedation need were assessed: treatment complexity, medical and behavioural indicators and patient reported anxiety using the Modified Dental Anxiety Scale. RESULTS: The findings suggest that 5% of the population are likely to require a course of treatment under sedation at some time. All three clinical domains contributed to the IOSN score and indication of treatment need. Females were 3.8 times more likely than males to be placed within the high need for sedation group. Factors such as age, deprivation and practice location were not associated with the need for sedation. CONCLUSIONS: Primary care trusts (PCTs) need health needs assessment data in order to commission effectively and in line with World Class Commissioning guidelines. This study provides both an indicative figure of need as well as a tool by which individual PCTs can undertake local health needs assessment work. Caution should be taken with the figure as a total need within a population as the study has only included those patients that attended dental practices.

Reducing postoperative pain by changing the process.

Untreated postoperative pain is an important ethical and financial issue that can lead to unnecessary suffering and prolonged stays in hospital. Despite the availability of effective analgesics and a growing body of published material that supports their use, postoperative pain remains a problem worldwide. To reduce acute postoperative pain, we introduced an intervention combining evidence-based analgesic protocols with the education of staff and patients on a surgical ward. The experiences of 68 patients before and 80 patients after the intervention were compared (worst pain scores, duration of pain, and satisfaction). Inadequately controlled pain was significantly reduced after the intervention, which suggests that the introduction of analgesic protocols supported by the education of staff and patients can be beneficial. Despite this, severe pain remained relatively common, indicating room for improvement. Duration of pain and patient satisfaction were not affected by the intervention, and patient satisfaction remained high throughout the study.

Interventions for replacing missing teeth: treatment of perimplantitis.

BACKGROUND: One of the key factors for the long-term success of oral implants is the maintenance of healthy tissues around them. Bacterial plaque accumulation induces inflammatory changes in the soft tissues surrounding oral implants and it may lead to their progressive destruction (perimplantitis) and ultimately to implant failure. Different treatment strategies for perimplantitis have been suggested, however it is unclear which are the most effective. OBJECTIVES: To identify the most effective interventions for treating perimplantitis around osseointegrated dental implants. SEARCH STRATEGY: We searched the Cochrane Oral Health Group's Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE. Handsearching included several dental journals. We checked the bibliographies of the identified randomised controlled trials (RCTs) and relevant review articles for studies outside the handsearched journals. We wrote to authors of all identified RCTs, to more than 55 dental implant manufacturers and an Internet discussion group to find unpublished or ongoing RCTs. No language restrictions were applied. The last electronic search was conducted on 9 January 2008. SELECTION CRITERIA: All RCTs comparing agents or interventions for treating perimplantitis around dental implants. DATA COLLECTION AND ANALYSIS: Screening of eligible studies, assessment of the methodological quality of the trials and data extraction were conducted in duplicate and independently by two review authors. We contacted the authors for missing information. Results were expressed as random-effects models using weighted mean differences for continuous outcomes and risk ratios for dichotomous outcomes with 95% confidence intervals (CI). Heterogeneity was to be investigated including both clinical and methodological factors. MAIN RESULTS: Ten eligible trials were identified, but three were excluded. The following procedures were tested: (1) use of local antibiotics versus ultrasonic debridement; (2) benefits of adjunctive local antibiotics to debridement; (3) different techniques of subgingival debridement; (4) laser versus manual debridement and chlorhexidine irrigation/gel; (5) systemic antibiotics plus resective surgery plus two different local antibiotics with and without implant surface smoothening; and (6) nanocrystalline hydroxyapatite versus Bio-Oss and resorbable barriers. Follow up ranged from 3 months to 2 years. The only statistically significant differences were observed in two trials judged to be at high risk of bias. After 4 months, adjunctive local antibiotics to manual debridement in patients who lost at least 50% of the bone around implants showed improved mean probing attachment levels (PAL) of 0.61 mm and reduced probing pockets depths (PPD) of 0.59 mm. After 6 months, patients with perimplant infrabony defects > 3 mm treated with Bio-Oss and resorbable barriers gained 0.5 mm more PAL (borderline difference) and PPD than patients treated with a nanocrystalline hydroxyapatite. AUTHORS' CONCLUSIONS: There is very little reliable evidence suggesting which could be the most effective interventions for treating perimplantitis. This is not to say that currently used interventions are not effective. The use of local antibiotics in addition to manual subgingival debridement was associated with a 0.6 mm additional improvement for PAL and PPD over a 4-month period in patients affected by severe forms of perimplantitis. After 6 months both augmentation therapies appeared to be successful but improved PAL and PPD (0.5 mm) were obtained when using Bio-Oss with resorbable barriers. In four trials, the control therapy which basically consisted of a simple subgingival mechanical debridement seemed to be sufficient to achieve results similar to the more complex and expensive therapies. Sample sizes were very small and follow up too short, therefore these conclusions have to be considered with great caution. Larger well-designed RCTs are needed.

Interventions for replacing missing teeth: maintaining and recovering soft tissue health around dental implants.

BACKGROUND: It is important to institute an effective supportive therapy to maintain or recover soft tissue health around dental implants. Different maintenance regimens have been suggested, however it is unclear which are the most effective. OBJECTIVES: To test the null hypotheses of no difference between different interventions (1) for maintaining healthy peri-implant soft tissues, and (2) for recovering soft tissue health, against the alternative hypothesis of a difference. SEARCH STRATEGY: We searched the Cochrane Oral Health Group's Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE. Handsearching included several dental journals. We checked the bibliographies of the identified randomised controlled trials (RCTs) and relevant review articles for studies outside the handsearched journals. We wrote to authors of all identified RCTs, to more than 55 oral implant manufacturers and to an internet discussion group to find unpublished or ongoing RCTs. No language restrictions were applied. The last electronic search was conducted on 13 June 2007. SELECTION CRITERIA: All randomised controlled trials comparing agents or interventions for maintaining or recovering healthy tissues around dental implants. DATA COLLECTION AND ANALYSIS: Screening of eligible studies, assessment of the methodological quality of the trials and data extraction were conducted in duplicate and independently by two review authors. Results were expressed as random-effects models using standardised mean differences for continuous data and risk ratios for dichotomous data with 95% confidence intervals. MAIN RESULTS: Eighteen RCTs were identified. Nine of these trials, which reported results from a total of 238 patients, were included. Follow ups ranged between 6 weeks and 1 year. No meta-analysis could be made since every RCT tested different interventions. Listerine mouthwash showed a reduction of 54% in plaque and 34% in marginal bleeding compared with a placebo. Two trials evaluated the efficacy of powered and sonic toothbrushes compared to manual toothbrushing and showed no statistically significant differences, though more patients liked the sonic brush. No statistical differences were found between brushing with a hyaluronic or a chlorhexidine gel, between cleaning with an etching gel or manually, between injecting a chlorhexidine or a physiologic solution inside the implant's inner part and between submucosal minocycline and a chlorhexidine gel. When an amine fluoride/stannous fluoride (AmF/SnF(2)) mouthrinse was compared with a chlorhexidine one, no statistically significant differences were found for implant failures and staining index while patients preferred and had less taste change with the AmF/SnF(2) mouthrinse. Self administered subgingival chlorhexidine irrigation resulted in statistically significantly lower plaque and marginal bleeding than a chlorhexidine mouthwash, however the mouthwash was given at a suboptimal dosage. AUTHORS' CONCLUSIONS: There was only little reliable evidence for which are the most effective interventions for maintaining or recovering health of peri-implant soft tissues. The included RCTs had short follow-up periods and few subjects. There was not any reliable evidence for the most effective regimens for long term maintenance. This should not be interpreted as current maintenance regimens are ineffective. There was weak evidence that Listerine mouthwash, used twice a day for 30 seconds, as an adjunct to routine oral hygiene, is effective in reducing plaque and marginal bleeding around implants. More RCTs should be conducted in this area. In particular, there is a definite need for trials powered to find possible differences, using primary outcome measures and with much longer follow up. Such trials should be reported according to the CONSORT guidelines (http://www.consort-statement.org/).

Interventions for replacing missing teeth: hyperbaric oxygen therapy for irradiated patients who require dental implants.

BACKGROUND: Dental implants offer one way to replace missing teeth. Patients who have undergone radiotherapy and those that have also undergone surgery for cancer in the head and neck region may benefit particularly from reconstruction with implants. Hyperbaric oxygen therapy (HBO) has been advocated to improve the success of implant treatment in patients who have undergone radiotherapy but this remains a controversial issue. OBJECTIVES: To compare success, morbidity, patient satisfaction and cost effectiveness of dental implant treatment carried out with and without HBO in irradiated patients. SEARCH STRATEGY: We searched the Cochrane Oral Health Group's Trials Register, The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE. Handsearching included several dental journals. We checked the bibliographies of relevant clinical trials and review articles for studies outside the handsearched journals. We wrote to authors of the identified randomised controlled trials (RCTs), to more than 55 oral implant manufacturers; we used personal contacts and we asked on an internet discussion group in an attempt to identify unpublished or ongoing RCTs. No language restriction was applied. The last electronic search was conducted on 13 June 2007. SELECTION CRITERIA: Randomised controlled trials of HBO therapy for irradiated patients requiring dental implants. DATA COLLECTION AND ANALYSIS: Screening of eligible studies, assessment of the methodological quality of the trials and data extraction were conducted in duplicate and independently by two review authors. Results were expressed as random-effects models using mean differences for continuous outcomes and risk ratios for dichotomous outcomes with 95% confidence intervals. MAIN RESULTS: Only one RCT was identified and included. Thirteen patients received HBO therapy while other 13 did not. Two to six implants were placed in fully edentulous mandibles to be rehabilitated with bar-retained overdentures. One year after implant loading four patients died from each group. One patient, treated with HBO, developed an osteoradionecrosis and lost all implants so the prosthesis could not be provided. Five patients in the HBO group had at least one implant failure versus two in the control group. There were no statistically significant differences for prosthesis and implant failures, postoperative complications and patient satisfaction between the two groups. AUTHORS' CONCLUSIONS: Despite the limited amount of clinical research available, it appears that HBO therapy in irradiated patients requiring dental implants may not offer any appreciable clinical benefits. There is a definite need for more RCTs to ascertain the effectiveness of HBO in irradiated patients requiring dental implants. These trials ought to be of a high quality and reported as recommended by the CONSORT statement (http://www.consort-statement.org/). Each clinical centre may have limited numbers of patients and it is likely that trials will need to be multicentred.