Antibiotic-Loaded Dendrimer Hydrogels in Periodontal Bone Regeneration: An In Vitro Release Feasibility Study.

The prescription of a course of oral antibiotics following bone grafting procedures is a common practice in clinical periodontics to reduce surgical site infections. The goal of this study is to characterize the release profile of antibiotics via local delivery using dendrimer hydrogels (DH) and to analyze the effect of two different particulate bone allografts on the release of the antibiotics in vitro. DH were synthesized from polyamidoamine (PAMAM) dendrimer G5 and polyethylene glycol diacrylate, and cefazolin was chosen as the antibiotic. The antibiotic-loaded samples were bathed in PBS and incubated at 37 °C; aliquots were taken (1 h, 2 h, 3 h, 4 h, 5 h, 6 h, 12 h, 24 h, 48 h, 72 h) and analyzed using HPLC to determine the amounts of released cefazolin. In samples with DH, the estimated maximum concentration of cefazolin was 36.97 ± 2.39 µg/mL (95% CI: 34.58-39.36) with 50% released in 4.17 h (95%: 3.26-5.07) and an estimated growth rate of 0.27 (95% CI: 0.17-0.37). For samples without DH, the estimated maximum concentration of cefazolin was 167.4 ± 7.0 µg/mL (95% CI: 160.4-174.4) with 50% released in 2.36 h (95% CI: 2.05-2.67) and an estimated growth rate of 0.70 (95% CI: 0.54-0.87). We conclude that DH are a promising platform for sustained antibiotic release and that the presence of bone grafts did not significantly affect their release.

Head and neck exam practices of dental professionals.

OBJECTIVE: Periodic examination of the head and neck includes screening for oral cancer, which is largely performed in dental offices by vigilant oral healthcare providers. The aim of this study was to assess practice patterns among Virginia dentists in performing head and neck exams and the referral rates of biopsies after completion of head and neck exams. We hypothesized that not all dentists perform head and neck exams and there is a difference between dentists who refer patients for a biopsy and those that perform biopsies. METHODS: General dentists and dental specialists who are members of the Virginia Dental Association were invited to participate in a cross-sectional survey study through REDCap to self-report their head and neck exam protocols. RESULTS: A total of 224 providers completed the survey. The majority of respondents were general dentists with more than 20 years in practice, who practice in a private setting, and see more than 10 patients in a day. All respondents stated they perform intraoral examinations, but 10 respondents stated they do not perform extraoral examinations. Nearly a third of respondents reported doing their own biopsies. CONCLUSIONS: Although only 8.5% of oral healthcare providers in Virginia responded to our survey, respondents are following the 2017 ADA good practice statement by providing their patients with head and neck exams to screen for oral cancer. Additional education pertaining to extraoral anatomy, malignant transformation of oral potentially malignant disorders, and pathology procedures may be helpful to clinicians.

Effect of clear aligner attachment design on extrusion of maxillary lateral incisors: A multicenter, single-blind randomized clinical trial.

INTRODUCTION: Extrusion of maxillary lateral incisors during aligner treatment is a difficult movement to achieve accurately. Despite recommendations regarding attachment design, few studies and no prospective trials compare predictability among attachments. This study aimed to compare the efficacy between optimized and horizontal attachment designs for achieving maxillary lateral incisor extrusion during clear aligner treatment. METHODS: The study included maxillary lateral incisors in 3 orthodontic practices requiring at least 0.3 mm of extrusion during the first series of 20-25 aligners in patients aged ≥16 years who were scheduled to begin clear aligner treatment (Invisalign; Align Technology, San Jose, Calif). Teeth were randomly assigned to receive optimized (O), rectangular horizontal nonbeveled (H), rectangular horizontal incisally-beveled (HIB), or rectangular horizontal gingivally-beveled (HGB) attachments. After the first series, a blinded evaluator measured extrusion using superimpositions with initial and predicted models. Linear models determined the difference in the predicted extrusion percentage achieved on the basis of attachment design. Other covariates were patient age, sex, number of trays, and self-reported compliance. RESULTS: Forty patients (74 teeth) were enrolled, and 38 patients (71 teeth) completed the study. Intraexaminer and interexaminer reliability for extrusion measurements was high (intraclass correlation coefficient, 0.985 and 0.991, respectively). The achieved extrusion was significantly less than predicted (mean, 73%; P <0.0001). The average achieved extrusion was 62%, 79%, 78%, and 78% for O, H, HIB, and HGB attachments, respectively, with H significantly more effective than O (P = 0.0403). Horizontal attachments (H, HIB, and HGB combined) were significantly more effective than O attachments (P = 0.0060), with an average difference in achieved extrusion of 14% of the predicted amount (95% confidence interval, 4-23; estimated 76% vs 62%). Horizontal attachments were an estimated 22% more effective than O attachments for extruding maxillary lateral incisors. CONCLUSIONS: Horizontal attachments are more effective than O attachments for predicted maxillary lateral incisor extrusion between 0.3 and 2.5 mm. The 3 horizontal attachment designs evaluated performed similarly for achieving predicted extrusion. TRIAL REGISTRATION: This randomized clinical trial was registered and reported at clinicaltrials.gov (NCT04968353). PROTOCOL: The protocol was not published before trial commencement. FUNDING: This study was funded in part by the Alexander Fellowship of the Virginia Commonwealth University School of Dentistry, the Southern Association of Orthodontists, and the Virginia Orthodontic Education and Research Foundation. No funding source influenced the study design, the collection, analysis or interpretation of data, writing of the report, or the decision to submit the article for publication.

Is pulpotomy an effective therapeutic option for the management of acute irreversible pulpitis in mature permanent teeth?

Clinical question Is cervical pulpotomy a viable treatment alternative to conventional root canal treatment for management of acute irreversible pulpitis in mature permanent teeth?Data sources A comprehensive literature search was performed on PubMed and Cochrane Library covering the years 2000-2021 for randomised clinical trials addressing the defined clinical question. The title and abstract were reviewed by two authors independently and any conflict was resolved by discussion with the third author.Study selection Only randomised controlled trials studies that compared cervical pulpotomy against non-surgical root canal treatment were included in this systematic review. Studies dealing with primary teeth or immature permanent teeth were excluded.Data extraction and synthesis Studies that reported clinical and radiographic success rate with a minimum follow-up of six months were included. The authors tabulated the data from primary sources without any synthesis.Results Only four studies fulfilled the inclusion/exclusion criteria. The results indicate that the clinical success rate of pulpotomy was comparable to root canal treatment while the radiographic success rate was higher in pulpotomy.Conclusions Pulpotomy is not inferior to the conventional root canal treatment for the management of acute irreversible pulpitis in mature permanent teeth in adults.

Which is the superior retrograde filling material? We don't know!

Clinical question Is Biodentine better than MTA as a root-end filling material?Data sources Cochrane, PubMed-Medline and Scopus databases were searched independently by two authors. In addition, a manual search was performed in high-quality endodontic journals.Data extraction and synthesis The name of the authors, the year of publication, sample size, the measurement method used, follow-up time for each of the three and main outcomes (bond strength, marginal gap and sealing ability) were extracted in the form of tables and evidence presented. The level of scientific evidence was assessed using Strength of Recommendation Taxonomy (SORT).Quality of included studies Not performed.Results A total of 13 publications were included and all of them were in vitro studies. With regards to bond strength, two of four studies indicated Biodentine performed better than MTA while the other two showed no significant difference. Microleakage studies and sealing ability indicated no clear superiority of one over the other.Conclusions Lack of scientific evidence regarding the superiority of tricalcium silicate over mineral trioxide aggregate as a root-end filling material in periapical surgery.

Peracetic Acid: A Practical Alternative to Formalin for Disinfection of Extracted Human Teeth.

Extracted human teeth provide the closest approximation to teeth in situ and play important roles in dental education and materials research. Since extracted teeth are potentially infectious, the Centers for Disease Control recommend their sterilization by autoclaving or disinfection by formalin immersion to ensure safe handling. However, autoclaving is not recommended for teeth with amalgam fillings and formalin is hazardous. The goal of the present study was to investigate the potential of peracetic acid (PA) as an alternative method to achieve reliable disinfection of freshly extracted teeth. A total of 80 extracted teeth were collected for this study. Whole teeth were incubated in one of four solutions for defined periods of time: sterile water (2 weeks), formalin (2 weeks), PA 1000 ppm (2 weeks), and PA 2000 ppm (1 week). After sectioning, the crown and root fragments were transferred into separate tubes containing brain-heart infusion broth and incubated at 37 °C under anaerobic conditions for 72 h. Absence of broth turbidity was used to assess effectiveness of disinfection. No turbidity was observed in any of the formalin-treated or peracetic acid-treated samples, signifying complete disinfection. Our results indicate that PA can effectively disinfect extracted human teeth, providing a reliable alternative to formalin and autoclaving.

Are single-visit regenerative endodontic procedures successful in treating non-vital, immature young permanent teeth?

Design Systematic review.Data sources PubMed and Scopus databases were searched independently by two authors from inception to July 2018 using keywords and index words combined using Boolean terms. Articles were restricted to English and were not excluded based on study design. Conference proceedings, grey literature, letters and commentaries were excluded.Data extraction and synthesis Demographic data (age, sex), study design, pulpal and periapical pre-treatment diagnosis, pre-operative radiographic findings, intra-operative disinfection protocol, intracanal coronal barrier, duration of follow-up, and clinical and/or radiographic and/or histological outcomes after completion of single-visit regenerative endodontic procedures (REPs) on non-vital, immature permanent teeth. Quality of included case reports were assessed according to the Joanna Briggs Institute Critical Appraisal Checklist. Risk of bias assessment of randomised controlled trials was done using Cochrane Collaboration's tool. The quality of the animal study was assessed by the SYRCLE risk of bias assessment tool.Results A total of five case reports, one randomised controlled trial and one animal study were included in the final analysis. All case reports were rated as high quality while the randomised controlled trial was rated moderate-to-low risk of bias. Case reports and the animal study favoured single-visit REPs, while the results from the randomised trial reported only 50% success. Within this limited pool of studies, there were differences in aetiology, location, disinfection protocol (different concentrations of NaOCl and EDTA, saline, chlorhexidine), follow-up time intervals and subjective reporting of radiographic healing, making syntheses challenging.Conclusions Single-visit REPs may offer benefits of reduced treatment time and visits compared to conventional two-visit REPs.

How can dentistry get back to work safely?

Data sources Narrative reviewStudy abstract This review provides a synopsis of our understanding of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and its associated coronavirus disease, COVID-19. The virus is shed in the nasopharyngeal and salivary secretions of carriers, and this puts dental professionals at risk for increased exposure of SARS-CoV-2. The paper summarises the current guidelines outlined by the CDC and presents the triaging protocols to identify potential carriers and how to safely limit treatment to low-risk patients.

Dietary Bioactive Fatty Acids as Modulators of Immune Function: Implications on Human Health.

Diet is major modifiable risk factor for cardiovascular disease that can influence the immune status of the individual and contribute to persistent low-grade inflammation. In recent years, there has been an increased appreciation of the role of polyunsaturated fatty acids (PUFA) in improving immune function and reduction of systemic inflammation via the modulation of pattern recognition receptors (PRR) on immune cells. Extensive research on the use of bioactive lipids such as eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) and their metabolites have illustrated the importance of these pro-resolving lipid mediators in modulating signaling through PRRs. While their mechanism of action, bioavailability in the blood, and their efficacy for clinical use forms an active area of research, they are found widely administered as marine animal-based supplements like fish oil and krill oil to promote health. The focus of this review will be to discuss the effect of these bioactive fatty acids and their metabolites on immune cells and the resulting inflammatory response, with a brief discussion about modern methods for their analysis using mass spectrometry-based methods.

Does orthodontic treatment in early adolescence positively influence psychosocial wellbeing in adulthood?

Design Prospective cohort study.Cohort selection A large cohort of 13-year-old children who participated in a South Australian population oral health study. a total of 1859 participants residing in metropolitan Adelaide were mailed a self-administered questionnaire when they turned 30 years of age.Data analysis Demographic data (sex, education level and income), dental behaviour (brushing habits, dental visits in past two years) and receipt of fixed orthodontic treatment were coded as dichotomous data. Psychosocial factors (self-efficacy, health competence, social support and optimism) were recorded on Likert scale as continuous measures. Severity of baseline malocclusion in untreated 13-year-olds was recorded using Dental Aesthetic Index (DAI).Regression analysis was performed to detect for associations between orthodontic treatment and each psychosocial factor and all independent variables were included in adjusted generalised linear models. Statistical significance level was set at p <0.05.Results Data from 448 participants (24%) informed the study results. Statistically significant association was found between low income (<80,00 AUD) and basic secondary education with each of the four psychosocial variables studied. Severity of baseline malocclusion (indicated by DAI) or prior orthodontic treatment was not associated with better psychosocial outcomes. Importantly, better psychosocial outcomes were observed among participants who had no prior orthodontic treatment.Conclusions Prior orthodontic treatment had no influence on psychosocial outcomes over the long-term.

Is calcium hydroxide more effective than formocresol or camphor phenol as intracanal disinfectants in acute pulpitis among deciduous teeth?

Data sources Cochrane Library, PubMed, Ovid, ScienceDirect, Wiley, China Biology Medicine (CBM), China National Knowledge Infrastructure (CNKI), Wan Fang and VIP Database for Chinese Technical Periodicals (VIP) databases were searched for articles dating from January 2000 to July 2018. Studies in languages other than English or Chinese were excluded.Study selection Randomised controlled trials comparing the clinical effectiveness of calcium hydroxide to formocresol or camphor phenol in acute pulpitis of deciduous teeth requiring root canal treatment were included. The primary outcome was clinical effectiveness while the secondary outcome was incidence of endodontic inter-appointment emergencies.Data extraction and synthesis Two authors independently screened titles and abstracts of all studies identified through the search and reviewed full articles against established inclusion/exclusion criteria. Any disagreements between the authors were resolved by consensus or by consulting relevant experts. Risk of bias assessment was carried out using the Cochrane collaboration tool. Clinical effectiveness and incidence of inter-appointment endodontic emergencies were expressed as odds ratio and 95% CI. Heterogeneity was assessed using Q-test and I2 measurement. Appropriate models were used for meta-analysis based on heterogeneity.Results A total of 16 randomised trials informed the meta-analysis. Clinical effectiveness of calcium hydroxide was compared to formocresol in 12 studies and pooled data indicate that calcium hydroxide was significantly better in terms of clinical effectiveness (OR = 3.37; 95% CI 2.54 to 4.48), and was associated with significantly decreased inter-appointment emergency visits (OR = 0.26; 95% CI 0.16 to 0.42) . Calcium hydroxide was compared to camphor phenol in seven studies and was shown to be significantly superior in its clinical effectiveness (OR = 5.50; 95% CI 3.36 to 8.98).Conclusions Limited available evidence suggest calcium hydroixide was superior to formocresol and camphor phenol as intracanal medicaments in the management of acute pulpitis in deciduous teeth.

Incorporation of Fibrin Matrix into Electrospun Membranes for Periodontal Wound Healing.

Guided tissue regeneration (GTR) aims to regenerate the lost attachment apparatus caused by periodontal disease through the use of a membrane. The goal of this study is to create and characterize a novel hybrid membrane that contains biologically active fibrin matrix within a synthetic polycaprolactone (PCL) electrospun membrane. Three-dimensional fibrin matrices and fibrin-incorporated electrospun membrane were created from fresh frozen plasma by centrifugation in glass vials under three different conditions: 400 g for 12 min, 1450 g for 15 min and 3000 g for 60 min. Half the membranes were crosslinked with 1% genipin. Degradation against trypsin indicated biologic stability while uniaxial tensile testing characterized mechanical properties. Continuous data was analyzed by ANOVA to detect differences between groups (p = 0.05). Fibrin-incorporated electrospun membranes showed statistically significant increase in mechanical properties (elastic modulus, strain at break and energy to break) compared to fibrin matrices. While crosslinking had marginal effects on mechanical properties, it did significantly increase biologic stability against trypsin (p < 0.0001). Lastly, membranes generated at 400 g and 1450 g were superior in mechanical properties and biologic stability compared to those generated at 3000 g. Fibrin-incorporated, crosslinked electrospun PCL membranes generated at lower centrifugation forces offers a novel strategy to generate a potentially superior membrane for GTR procedures.

Which surgical approach for palatally displaced canines?

Data sourcesCochrane Oral Health's Trials Register, Cochrane Central Register of Controlled Trials, Medline Ovid and Embase Ovid (up to February 2017); ongoing clinical trials were searched in clinicaltrials.gov as well as the World Health Organization International Clinical Trials Registry. Reference lists of included studies and relevant systematic reviews were searched. No restrictions were placed on the language or date of publication and study authors were contacted when necessary.Study selectionRandomised and quasi-randomised controlled trials assessing open and closed surgical exposures in palatally displaced canines with no restriction on age, presenting malocclusion or type of orthodontic treatment. Unilaterally and bilaterally displaced canines were included in the review. The primary outcomes considered were sufficient eruption of the canine to allow orthodontic alignment without requiring additional surgery, post surgical complications and aesthetics.Data extraction and synthesisTwo authors independently screened titles and abstracts of all studies identified through the search and reviewed full articles against established inclusion criteria. Any disagreements between the authors were resolved by consensus or by consulting an expert. Risk of bias assessment was done using Cochrane Collaboration's tool and study authors were contacted for missing information. Dichotomous outcomes (success of surgery - yes or no) were expressed as risk ratio and 95% CI. Continuous outcomes (pain on VAS scale) were expressed as mean differences (MD) or standardised mean differences (if different scales were used).ResultsA total of three studies (six articles) representing 146 participants were included in the SR. One was an RCT while the other two were quasi-RCTs. With regards to successful eruption, there was no evidence of a difference between the open and closed groups (RR 0.99, 95% CI 0.93-1.06, P = 0.79). Other primary measures (including surgical complications or aesthetics) or secondary measures were either reported in just one trial or used different measures, so pooling of data was not possible.ConclusionsLimited available evidence suggests surgical exposure of palatally displaced canines is successful in bringing canines into alignment. However, data do not support one technique over the other (closed vs open). One trial was at low risk of bias while the others were at high risk of bias. This adds to the uncertainty of the conclusions.

Mesenchymal Stem Cells Derived from Healthy and Diseased Human Gingiva Support Osteogenesis on Electrospun Polycaprolactone Scaffolds.

Periodontitis is a chronic inflammatory disease affecting almost half of the adult US population. Gingiva is an integral part of the periodontium and has recently been identified as a source of adult gingiva-derived mesenchymal stem cells (GMSCs). Given the prevalence of periodontitis, the purpose of this study is to evaluate differences between GMSCs derived from healthy and diseased gingival tissues and explore their potential in bone engineering. Primary clonal cell lines were established from harvested healthy and diseased gingival and characterized for expression of known stem-cell markers and multi-lineage differentiation potential. Finally, they were cultured on electrospun polycaprolactone (PCL) scaffolds and evaluated for attachment, proliferation, and differentiation. Flow cytometry demonstrated cells isolated from healthy and diseased gingiva met the criteria defining mesenchymal stem cells (MSCs). However, GMSCs from diseased tissue showed decreased colony-forming unit efficiency, decreased alkaline phosphatase activity, weaker osteoblast mineralization, and greater propensity to differentiate into adipocytes than their healthy counterparts. When cultured on electrospun PCL scaffolds, GMSCs from both sources showed robust attachment and proliferation over a 7-day period; they exhibited high mineralization as well as strong expression of alkaline phosphatase. Our results show preservation of 'stemness' and osteogenic potential of GMSC even in the presence of disease, opening up the possibility of using routinely discarded, diseased gingival tissue as an alternate source of adult MSCs.

Topical intra-pocket anaesthetic gel reduces the risk and intensity of pain during periodontal scaling and root planing and probing.

Data sourcesMedline, Scopus, Web of Science, LILACS, BBO, Cochrane Library, SIGLE, ProQuest Dissertations and Theses, Periódicos Capes Theses, Current Controlled Trials, International Clinical Trials Registry Platform, the ClinicalTrials.gov, Rebec (www.rebec.gov.br), EU Clinical Trials Register (www.clinicaltrialsregister.eu), abstracts of the annual conference of the International Association for Dental Research (IADR) and its regional divisions. Reference lists of primary studies and related articles from PubMed.Study selectionRandomised controlled trials, parallel, crossover or split-mouth designs comparing intra-pocket anaesthesia with an anaesthetic gel with placebo in patients requiring periodontal probing or SRP were considered.Data extraction and synthesisTwo authors shortlisted 11 final articles based on the inclusion criteria. Data extraction was performed by three authors using customised forms after calibration. The risk of bias in the included studies was evaluated using the Cochrane collaboration tool for assessing risk of bias in randomised controlled trials.1ResultsThe authors used VAS and Heft-Parker scale to measure pain intensity and reported Hedge's g standardised difference in the means. The mean reduction in VAS and Heft-Parker scale were - 0.576 (CI = - 0.94 to - 0.22; p = 0.002) and - 1.814 (CI = - 3.38 to - 0.245; p = 0.023) respectively. This indicates a positive effect of anaesthetic gel in pain intensity reduction. For risk of pain, the authors reported the odds ratio of 0.025 (CI 0.003-0.25; p = 0.002). As far as the need for rescue anaesthesia using the same anaesthetic gel and/or injected anaesthetics, the odds ratio was 0.358 (95% CI 0.174-0.736; p = 0.005). Both these findings show the efficacy of anaesthetic gel in controlling the risk of pain during SRP and probing.ConclusionsThe risk and intensity of pain during probing and SRP as well as the need for additional rescue anaesthesia using the same anaesthetic gel and/or injected anaesthetics is reduced with the application of topical intra-pocket anaesthetic gel.

Fixed and removable orthodontic retainers and periodontal health.

Data sourcesMedline, PubMed, Cochrane Central Register of Controlled Trials, LILACS and BBO databases with no language restrictions; unpublished literature was searched in Proquest Dissertations and Theses database, clinicaltrials.gov and controlled-trials.com.Study selectionRandomised and nonrandomised controlled clinical trials, prospective cohort studies, and case series (with a minimum sample size of 20 patients) in patients who underwent fixed or removable appliance orthodontic therapy with a minimum follow-up period of six months. The primary outcome was periodontal health; while failure rates, impact of orthodontic retainers on patient-reported outcomes and cost-effectiveness served as secondary outcomes.Data extraction and synthesisFull texts of relevant abstracts were retrieved and data extracted using pre-piloted data collection forms by two authors. Study quality was assessed with Cochrane Collaboration's Risk of Bias tool (RCTs) and Newcastle-Ottawa Scale (NOS) for non-randomised studies. Only RCTs at low or unclear risk of bias and non-randomised studies of moderate or high methodological quality were included in the meta-analysis (MA). If moderate to high heterogeneity was present (I2 > 50%), MA was not performed.ResultsOut of the 18 included RCTs, 11 were assessed to be of low risk of bias while five out of six prospective cohort studies were considered high quality using the NOS. The authors did not perform MA because of significant heterogeneity that existed among different studies.With regards to periodontal health, there was no significant difference in probing depth and bleeding on probing between fixed mandibular stainless steel (SS) retainers (bonded to anterior teeth or canines only), fibre reinforced composite retainers or Hawley retainers at three-year follow-up. However, there was increased plaque accumulation around fibre reinforced composite retainers compared to SS retainers. The failure rates of mandibular stainless steel fixed retainers bonded from canine to canine was 0.29 (95 % confidence interval [CI], 0.26, 0.33) over a follow-up period of six to 36 months. The failure risk for mandibular stainless steel fixed retainers bonded to canines only was 0.25 (CI, 0.16, 0.33) over a follow-up period of one to three years. A meta-regression showed that follow-up period was not a predictor of failure rate for mandibular stainless steel fixed retainers. The failure rates of removable retainers (Hawley's or vacuum formed retainers) are lower than the bonded fixed retainers. Removable Hawley's retainer was associated with increased discomfort as well as higher levels of embarrassment with speech and aesthetics. In terms of cost-effectiveness, vacuum-formed retainers were found to be significantly more cost-effective than Hawley retainers or mandibular stainless steel fixed retainers bonded to canines.ConclusionsThere is a lack of high-quality evidence to endorse the use of one type of orthodontic retainer based on their effect on periodontal health, risk of failure, patient-reported outcomes and cost-effectiveness.

Are there more adverse effects with lingual orthodontics?

Data sourcesPubMed, Embase, Cochrane Library and LILACS database, review of references cited in included articles and a manual search of leading orthodontic journals. No language restrictions were imposed in the search. Study authors were contacted when necessary.Study selectionRandomised controlled trials (RCTs) and controlled clinical trials (CCTs) in healthy patients that directly compared the adverse effects following treatment using buccal and lingual appliances. Studies involving single arch or dual arch appliances were considered. Studies on patients with systemic diseases, animal studies and in vitro studies were excluded. The primary outcomes of interest to the authors were a list of adverse effects: pain, caries, eating and speech difficulties and oral hygiene.Data extraction and synthesisTwo authors reviewed the titles and abstracts of all studies identified through the search without blinding to names of authors or publication dates. Selected articles from searches were evaluated independently by two authors against established inclusion criteria, disagreements were resolved by consensus or by consulting a third author. Two authors independently assessed the risk of bias using the Cochrane Collaboration's tool (randomised trials) and the Newcastle-Ottawa Scale for non-randomised studies. The level of agreement between the authors was assessed using the Cohen kappa statistic. A meta-analysis was performed to provide pooled effect estimate (expressed as odds ratio) as well as 95% confidence interval. The outcomes of interest were pain, caries, eating difficulties, speech difficulties and deficient oral hygiene. Heterogeneity was quantified using I2 statistic and potential causes explored. Publication bias was assessed using a funnel plot.ResultsEight articles were included; three RCTs and five CCTs. One RCT was considered to be at high risk of bias, one moderate risk and one low risk. Of the non-randomised studies, four were low risk and one was high risk of bias. Six studies involving a total of 131 patients were included in a meta-analysis. The lingual appliance was associated with significant pain in the tongue (OR=28.32, 95% CI 8.6-93.28), difficulty in maintaining oral hygiene (OR=3.49, 95%CI 1.02-11.95) and greater speech difficulty (OR = 9.39, 95% CI 3.78-23.33) compared to buccal appliances. On the other hand, patients with lingual appliances had decreased pain in the lips and cheeks. There was no difference between the two appliances with regards to caries risk.ConclusionsLimited available evidence indicates that lingual orthodontic appliances are associated with increased pain in the tongue, speech difficulties and difficulty in maintaining oral hygiene.

Limited evidence shows short-term benefit of probiotics when used as an adjunct to scaling and root planing in the treatment of chronic periodontitis.

Data sourcesMedline, Cochrane Central Register of Controlled Trials and Science Direct databases. Hand searches of the Journal of Clinical Periodontology, Journal of Periodontology, Journal of Periodontal Research, Journal of Dental Researc h and reference searches of the included articles and related reviews.Study selectionTwo authors independently screened the literature to identify relevant randomised controlled trials (RCTs) on patients with chronic periodontitis (CP) treated with SRP and probiotic, SRP and placebo or SRP alone, with pocket probing depth (PPD) as the primary outcome. No minimum follow-up period was set for study inclusion.Data extraction and synthesisRisk of bias assessment was done independently using the Cochrane tool. Data were extracted using a predefined form. Weighted mean differences and 95% confidence intervals were calculated and meta-analysis conducted using fixed and random effects models.ResultsThree of the four included studies were included for meta-analysis. All three studies showed significant heterogeneity though they were rated as having low risk of bias. The number of patients ranged between 30 and 40 and follow-up duration ranged between 42 and 360 days amongst these studies. The reported primary outcomes were PPD and clinical attachment level (CAL); bleeding on probing, gingival index, gingival bleeding index, need for surgery and risk of disease progression were reported as secondary outcomes.Overall, the authors did not find a statistically significant reduction in PPD [-0.46mm, (-0.95, 0.02; p = 0.06)] in the probiotic group. However, when pockets were stratified as moderate and deep pockets, probiotic group showed significant reduction in PPD in moderate [0.18, (-0.28, -0.07; p = 0.01)] and deep pockets [-0.67, (-0.85, -0.49; p<0.001)]. The overall CAL gain [-0.42mm (-0.68, -0.16; p = 0.002)] and reduction in BOP [-14.66% (-24.49, -4.83; p = 0.003)] were significant in the probiotic group short-term.ConclusionsThe meta-analysis shows some beneficial effect of Lactobacillus reuteri with reduction of PPD especially in deep periodontal pockets, CAL gain was similar to other adjuncts.1, 2 However, studies with larger number of patients and longer-term follow-up are needed to confirm these findings.

Fixed or removable function appliances for Class II malocclusions.

Data sourcesEmbase, Cochrane Central Register of Controlled Trials, Medline (Pubmed), Web of Science, Google Scholar, Scopus, LILACS database and bibliographies of clinical trials encountered during search. There was no restriction on language or date during search.Study selectionRandomised Controlled Trials (RCTs) and Controlled Clinical Trials (CCT) in patients with Class II malocclusions that compared at least one fixed functional appliance with at least one removable functional appliance (RFA) in children below 16 years of age. Primary outcomes were clinical and lateral cephalometric measurements and the duration of treatment. Secondary outcomes included patient experiences of treatment, quality of life measures and harms arising during treatment as well as costs of both treatments.Data extraction and synthesisThe titles and abstracts of all studies identified through the search were assessed independently and in duplicate by two review authors. Disagreements about included studies were resolved through discussion with the third author. Heterogeneity was assessed using customised forms and risk of bias using a Cochrane Collaboration tool. A meta-analysis was planned for studies at low risk of bias with similar comparisons reporting the same outcome.ResultsTwo RCTs and two CCTs that met the inclusion/exclusion criteria were included in the final analysis. Risk of bias assessment indicated three trials were at high risk while one was unclear. Consequently, the included trials were deemed to be inappropriate for meta-analysis (MA).Two studies with 282 participants evaluated Twin Block with fixed Herbst appliance and reported significant improvements in anterior-posterior skeletal discrepancy, mandibular length and reduction of overjet with both appliances. While one study reported significantly shorter treatment duration in Herbst appliance, the other study did not find any difference. Herbst appliance had better compliance, less dropouts but more emergency visits.One trial that compared activator appliance with Twin Force Bite Corrector found significantly shorter time with the fixed appliance. However, effective length and sagittal positioning of the mandible was not different between the groups.One trial comparing activator with Forsus FRZ reported enhanced mandibular growth and restrained maxillary growth with both the appliances. While activator appliance was associated with increased posterior facial height, Forsus significantly rotated the occlusal plane.ConclusionsLimited available evidence indicates that both fixed and removable functional appliances are effective in reducing overjet in growing children. However, there is insufficient evidence to differentiate between the two types with respect to biological (skeletal and dental) effects or patient experiences.