Efficacy and Safety of Postoperative Medications in Reducing Pain after Nonsurgical Endodontic Treatment: A Systematic Review and Network Meta-analysis.

INTRODUCTION: The purpose of this study was to evaluate the efficacy and safety of postoperative medications in decreasing pain after nonsurgical endodontic treatment using a network meta-analytic approach. METHODS: MEDLINE, Embase, CENTRAL, CINAHL, and Scopus were searched (until July 31, 2019). Two reviewers selected eligible randomized controlled trials and extracted and meta-analyzed data to estimate the treatment effects of pain assessed on a 0-100 scale (mean difference [MD]); 95% credible interval [CrI], and surface under the cumulative ranking curve [SUCRA]) at 6-8, 12, 24, and 48 hours postoperatively after the administration of various interventions. The Cochrane risk of bias tool was applied to eligible trials. The overall quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation approach obtained from the CINeMA Web application (University of Bern, Bern, Switzerland). RESULTS: Eight interventions among 11 studies were identified: nonsteroidal anti-inflammatory drugs (NSAIDs), NSAIDs + acetaminophen, NSAIDs + benzodiazepines, NSAIDs + opioids, corticosteroids, opioids, acetaminophen, and placebo. Compared with placebo, nonsurgical endodontic treatment pain 6-8 hours postoperatively improved with NSAIDs + acetaminophen (MD = -22; 95% CrI, -38 to -7.2; SUCRA = 73%; moderate confidence) and NSAIDs (MD = -21; 95% CrI, -34 to -7.6; SUCRA = 68%; very low confidence). At 12 and 24 hours, only NSAIDs were effective in decreasing postoperative pain. At 48 hours, no treatment resulted in significant pain reduction. Corticosteroids and opioids did not significantly decrease pain. No major safety concerns were reported. CONCLUSIONS: Very low- to moderate-quality evidence suggests that NSAIDs or NSAIDs + acetaminophen administered after nonsurgical endodontic treatment lead to a clinically relevant decrease in postoperative pain for patients with irreversible pulpitis or pulpal necrosis and are the most effective treatments available. Postoperative corticosteroids or opioids did not significantly decrease postoperative pain.

Efficacy and Safety of Pulpal Anesthesia Strategies during Endodontic Treatment of Permanent Mandibular Molars with Symptomatic Irreversible Pulpitis: A Systematic Review and Network Meta-analysis.

INTRODUCTION: Several strategies have been investigated for achieving successful pulpal anesthesia during endodontic treatment of mandibular molars with symptomatic irreversible pulpitis. However, comprehensive evaluation and identification of the most efficacious and safe intervention are lacking. We aimed to determine this using network meta-analysis. METHODS: MEDLINE, Embase, Cochrane Central, CINAHL, and Scopus databases were searched. Study selection and data extraction were performed in duplicate. Eligible randomized controlled trials were meta-analyzed to estimate the treatment effects (odd ratios [ORs]; 95% credible interval (CrI) and surface under the cumulative ranking curve (SUCRA)]. CINeMA software (University of Bern, Bern, Switzerland) was used to assess the quality of results. RESULTS: Thirty-seven interventions from 46 studies were identified. Compared with the common practice of an inferior alveolar nerve block with 2% lidocaine, a supplemental intraosseous injection was ranked the most efficacious with very low to moderate confidence (2% lidocaine + preoperative nonsteroidal anti-inflammatory drugs [NSAIDs] + acetaminophen [OR = 74; 95% CrI, 15-470; SUCRA = 97%], 2% lidocaine + preoperative NSAIDs [OR = 46; 95% CrI, 8-420; SUCRA = 94%], 2% lidocaine [OR = 33; 95% CrI, 14-80; SUCRA = 93%], 2% lidocaine + preoperative opioids + acetaminophen [OR = 20; 95% CrI, 4.4-98; SUCRA = 86%], and 4% articaine [OR = 20; 95% CrI, 6.3-96; SUCRA = 87%]) followed by supplemental buccal and lingual infiltrations using 4% articaine + preoperative NSAIDs (OR = 18; 95% CrI, 6-56; SUCRA = 86%; very low confidence). No major safety concerns were reported. CONCLUSIONS: Very low- to moderate-quality evidence suggests intraosseous injection using 2% lidocaine with 1:100,000 epinephrine or 4% articaine with 1:100,000 epinephrine or buccal and lingual infiltrations of 4% articaine with 1:100,000 epinephrine are superior strategies to achieve pulpal anesthesia during endodontic treatment of mandibular molars with symptomatic irreversible pulpitis. Preoperative NSAIDs or opioids with or without acetaminophen may increase the efficacy of these injections.

Chlorhexidine-Related Mortality Rate in Critically Ill Subjects in Intensive Care Units: A Systematic Review and Meta-Analysis.

BACKGROUND: This meta-analysis aimed to explore the chlorhexidine-related mortality rate for subjects on mechanical ventilation and in an ICU when compared with subjects who received standard ICU care. METHODS: We searched a number of medical literature databases and the first 100 results in an internet search. Two of us independently reviewed the titles and abstracts of the identified articles. Then general and specific characteristics from eligible articles were extracted and the quality of included trials were appraised by using a risk of bias assessment tool. Risk ratios were calculated, together with the 95% CI. Random-effects models with the Mantel-Haenszel method were used to estimate pooled probabilities. Heterogeneity was identified and quantified via the chi square test and I2 values, respectively. RESULTS: Eleven of the 547 studies were suitable for this meta-analysis. The included participants were critically ill adults in ICU settings of high-income countries (n = 1157) and low/ middle-income countries (n = 612). They were assigned to either the chlorhexidine or control groups. Overall, moderate-quality evidence indicated reduced ventilator-associated pneumonia incidence (for high-income countries: RR 0.60, 95% CI 0.41-0.87; P = .008; I2 = 39%; and for low- and middle-income countries: RR 0.71, 95% CI 0.51-0.99; P = .05; I2 = 10%), without a substantial effect on mortality rate (for high-income countries: RR 1.01, 95% CI 0.65-1.57; P = .96; I2 = 42%; and for low- and middle-income countries: RR 1.11, 95% CI 0.96-1.29; P = .17; I2 = 0%). CONCLUSIONS: The prophylactic administration of chlorhexidine among patients who were critically ill and in an ICU setting reduced the occurrence of ventilator-associated pneumonia with no significant impact on associated mortality.

Knowledge and Practices of Family and Emergency Physicians in Managing Nontraumatic Dental Conditions: A Case-based Survey.

INTRODUCTION: Physicians are often patients' first point of contact for management of nontraumatic dental conditions (NTDCs). This study's aim was to evaluate the knowledge and practices of Ontario physicians in managing NTDCs, with a specific focus on antibiotic usage. METHODS: A Web-based survey featured 4 NTDC clinical scenarios: irreversible pulpitis, localized acute apical abscess with or without systemic involvement, and chronic apical abscess. The survey link was distributed to active Ontario family and emergency physicians. The sample group was asked questions about their management of and experience with NTDCs, and demographic and practice characteristics were collected. Descriptive and multivariate logistic regression analyses were undertaken (P ≤ .05). RESULTS: Sampled Ontario physicians tend to manage NTDCs in a manner that is not consistent with evidence-based care. For irreversible pulpitis and for localized acute apical abscess with or without systemic involvement, most physicians would prescribe an antibiotic (57.4%, 84.8%, and 96.3%, respectively), and 23.5% would prescribe an antibiotic for chronic apical abscess. Approximately half the sample (52.9%) felt discomfort in managing NTDCs, and 85.3% felt they were inadequately trained to manage NTDCs. CONCLUSION: Areas that present opportunities for improvement in the physician management of NTDCs were identified, including the incorporation of further NTDC training in medical curricula and continuing medical education courses, and development and dissemination of guidelines for physicians in managing NTDCs.