Treatment outcomes of regenerative endodontic therapy in immature permanent teeth with pulpal necrosis: A systematic review and network meta-analysis.

AIM: The aim of this study was to assess which treatment modality regarding scaffold selection for immature permanent teeth with pulpal necrosis will be the most successful for regenerative endodontic treatment (RET). METHODOLOGY: PubMed, Cochrane, Web of Science and Embase, and additional records until August 2022 were searched providing a total of 3021 articles, and nine of these articles were included for quantitative synthesis. The reviewers selected eligible randomized controlled trials and extracted pertinent data. Network meta-analysis was conducted to estimate treatment effects for primary outcomes (clinical and radiographic healing) and secondary outcomes (apical closure, root length and root wall thickness increase) following RET [mean difference (MD); 95% credible interval (CrI) and surface under the cumulative ranking curve (SUCRA)]. The quality of the included studies was appraised by the revised Cochrane risk of bias tool, and the quality of evidence was assessed using the GRADE approach. RESULTS: Six interventions from nine included studies were identified: blood clot scaffold (BC), blood clot scaffold with basic fibroblast growth factor, blood clot scaffold with collagen, platelet pellet, platelet-rich plasma (PRP) and platelet-rich fibrin (PRF). The PRP scaffold showed the greatest increase in root lengthening at 6-12 months (MD = 4.2; 95% CrI, 1.2 to 6.8; SUCRA = 89.0%, very low confidence). PRP or PRF achieved the highest level of success for primary and secondary outcomes at 1-6 and 6-12 months. Blood clot scaffold (with collagen or combined with basic fibroblast growth factor (bFGF)) achieved the highest level of success for secondary outcomes beyond 12 months follow-up. A very low to low quality of evidence suggests that both PRP and PRF exhibit the greatest success evaluating primary and secondary outcomes within 12 months postoperatively compared to the traditional blood clot scaffold protocol. CONCLUSION: Limited evidence suggests both PRP and PRF exhibit success in the short-term, not long-term. The value of this information stems in its recommendation for future randomized trials prioritizing both of these materials in their protocol.

ADJUNCTIVE ANTIBIOTICS MAY REDUCE PROBING DEPTH, INCREASE BONE LEVEL GAIN, AND CONTRIBUTE TO OVERALL SUCCESS IN PERI-IMPLANTITIS TREATMENT FOR UP TO 12 MONTHS POSTOPERATIVELY.

ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION: Wang Y, Chen CY, Stathopoulou PG, Graham LK, Korostoff J, Chen YW. Efficacy of Antibiotics Used as an Adjunct in the Treatment of Peri-implant Mucositis and Peri-implantitis: A Systematic Review and Meta-analysis. Int J Oral Maxillofac Implants. 2022 Mar-Apr;37(2):235-249. doi:10.11607/jomi.9220. PMID: 35476853. SOURCE OF FUNDING: None. TYPE OF STUDY/DESIGN: Systematic review with meta-analysis of data.

The effect of hard tissue defects on the clinical outcome of endodontic microsurgery: a systematic review and meta-analysis.

OBJECTIVES: The purpose of this systematic review was to appraise the existing literature on the effect of hard tissue defects on the clinical outcome of endodontic microsurgery (EMS). METHODS: MEDLINE (PubMed), Embase, Web of Science, Cochrane Library and grey literature were searched from January 2000 to May 2023. Study selection and data extraction were performed in duplicate. Eligible studies were critically appraised for the risk of bias using the Cochrane Risk of bias tool. The quality of evidence was assessed using GRADE. Review Manager (RevMan Computer program Version 5.4, The Cochrane Collaboration, 2020) was utilized and the Mantel Haenszel fixed or random effects model was applied, depending on the heterogeneity of the studies. Meta-analysis was performed to estimate the Risk ratio (RR) and 95% Confidence Interval (CIs) to correlate the effects of these factors on treatment outcomes. RESULTS: Nineteen studies were included. The EMS overall pooled success rate was 84.5%. Five characteristics of hard tissue were identified. The size of the lesion (Small ≤ 5 mm: 78.4% vs. Large > 5 mm: 63.3%, RR = 1.12, 95% CI 1.00-1.26, P ≤ .05), significantly affected the outcomes of EMS. Endodontic lesions exhibited slightly better outcomes than endodontic-periodontal lesions (81.4% vs. 68.2%, RR = 1.14 95% CI 0.98-1.33, P > .05). Cases with the height of the buccal bone > 3 mm also exhibited slightly better outcomes (91.5% vs. 71.4%, RR = 1.20, 95% CI 0.88-1.62, P > .05). Additionally, through and through lesions exhibited better outcomes when grafting was completed during the EMS procedure both in 2D (RR = 1.12 95% CI 0.97-1.29, P > .05) and 3D evaluation ((RR = 1.28 95% CI 0.69-2.37 P > .05). The overall quality of evidence was graded as low to high. CONCLUSION: With a low to high quality of evidence, the size of the lesion is a key prognostic variable that significantly affects the outcome of EMS, as lesions ≤ 5 mm exhibit better outcomes as compared to larger lesions. CLINICAL SIGNIFICANCE: The presence of hard tissue defects can affect the outcome of endodontic microsurgery (EMS). The presented data can aid the clinicians' decision-making process by examining certain pre-operative prognostic variables, when considering EMS as a treatment option. Clinical cases with more favorable hard tissue characteristics lead to a better prognosis in EMS.

Surgical Therapy in Patients With Medication-Related Osteonecrosis of the Jaw Is Associated With Disease Resolution and Improved Quality of Life: A Prospective Cohort Study.

PURPOSE: Although recent evidence has suggested the value of operative therapy for the management of medication-related osteonecrosis of the jaw (MRONJ), its effectiveness remains controversial. The purpose of this study was to measure and compare MRONJ disease resolution and changes to the quality of life (QoL) between operative and nonoperative management of MRONJ. METHODS: This is a prospective cohort study. Consecutive MRONJ patients presenting to Mount Sinai Hospital and Sunnybrook Health Sciences Center (September 2016 to August 2020) were recruited and divided by the treatments provided into operative and nonoperative groups. The primary and secondary outcome variables were disease resolution and QoL at 6 months, respectively. Disease resolution was defined as mucosal coverage with an absence of pain, and QoL was measured via the MRONJ-QoL questionnaire. The primary and secondary outcomes, after adjusting for potential confounders, were assessed via multivariate logistic regression and multivariate linear regression analyses, respectively, with significance set to P < .05. RESULTS: Sixty patients were included in this study. Of these, 40 patients received operative treatment, and 20 received nonoperative treatment. In the unadjusted analyses, operative therapy was found to be significantly associated with both disease resolution and improvement in QoL (relative risk 6.75, 95% confidence interval [CI] 1.78 to 25.6, P < .001; and MRONJ-QoL score improvement of 3.35, 95% CI 0.16 to 6.54, P = .04). When controlling for potential confounders, operative therapy was found to be significantly associated with disease resolution when compared with nonoperative therapy (adjusted odds ratio 46.2, 95% CI 5.57 to 383.9, P < .001). Linear regression analysis also showed operative therapy to be significantly associated with improved QoL compared with nonoperative therapy (adjusted MRONJ-QoL score improvement of 3.72, 95% CI 0.34 to 7.11, P = .03). CONCLUSIONS: Our study demonstrated operative therapy to be significantly associated with disease resolution and improvement in QoL.

Human amniotic membrane extracellular matrix scaffold for dental pulp regeneration in vitro and in vivo.

AIM: In order to obtain a 3-dimentional scaffold with predictable clinical results for pulp regeneration, this study aims to fabricate and characterize a porous decellularized human amniotic membrane (HAM) extracellular matrix (ECM) scaffold, and evaluate its potential to promote pulp regeneration in vitro and in vivo. METHODOLOGY: The HAM was decellularized, and its histology and DNA content were analysed to confirm decellularization. The scaffolds were synthesized with 15, 22.5 and 30 mg/ml concentrations. The porosity, pore size, phosphate-buffered saline (PBS) absorption and degradation rate of the scaffolds were assessed. In vitro experiments were performed on human dental pulp stem cells (hDPSCs) to assess their viability, proliferation, adhesion and migration on the scaffolds. The optimal group was selected for in vivo immunogenicity assessment and was also used as the cell-free or cell-loaded scaffold in root segment models to evaluate pulp regeneration. All nonparametric data were analysed with the Kruskal-Wallis test followed by Dunn's post hoc test, whilst quantitative data were analysed with one-way anova. RESULTS: Decellularization of HAM was confirmed (p < .05). The porosity of all scaffolds was more than 95%, and the pore size decreased with an increase in ECM concentration (p < .01). PBS absorption was not significantly different amongst the groups, whilst 30 mg/ml ECM scaffold had the highest degradation rate (p < .01). The hDPSCs adhered to the scaffold, whilst their proliferation rate increased over time in all groups (p < .001). Cell migration was higher in 30 mg/ml ECM scaffold (p < .05). In vivo investigation with 30 mg/ml ECM scaffold revealed mild to moderate inflammatory response. In root segments, both cell-free and cell-loaded 30 mg/ml scaffolds were replaced with newly formed, pulp-like tissue with no significant difference between groups. Immunohistochemical assessments revealed high revascularization and collagen content with no significant difference amongst the groups. CONCLUSION: The 30 mg/ml HAM ECM scaffold had optimal physical properties and better supported hDPSC migration. The HAM ECM scaffold did not interfere with formation of pulp-like tissue and revascularization within the root canal when employed as both cell-free and cell-loaded scaffold. These results highlight the potential of HAM ECM membrane for further investigations in regenerative endodontics.

The applications of ultrasound, and ultrasonography in dentistry: a scoping review of the literature.

OBJECTIVES: This scoping review aims to summarize the available literature on the clinical applications of ultrasonography and ultrasound in diagnostic, therapeutic, and interventional dental applications. MATERIALS AND METHODS: We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, Extension for Scoping Reviews checklist and conducted a protocol-driven scoping review of randomized controlled trials, cohort studies, cross-sectional studies, case-control studies, and case series that assessed ultrasonography or ultrasound use as a stand-alone diagnostic, therapeutic, and interventional tool in dentistry. We included studies published after 1980, study samples ≥ 10, with diagnostic, concordance, or therapeutic outcomes. We searched Ovid MEDLINE, Embase, and others (up to April 2021) and extracted information regarding study level, patient level, test or treatment level, and outcome level data. RESULTS: Five interventional studies (related to oral medicine, temporomandibular disorders, and dental anesthesia), eight therapeutic studies (related to surgery and orthodontics), and seventy-five diagnostic studies (related to orthodontics, surgery, endodontics, oral medicine, temporomandibular disorders, restorative dentistry, and periodontology) were identified and presented in this review. CONCLUSION: Ultrasonography has a well-established niche in diagnostic dentistry, while therapeutic and interventional ultrasounds have a smaller, yet present, niche in dentistry. However, further research is needed to report the precise estimates of the diagnostic, therapeutic, and interventional effects. CLINICAL SIGNIFICANCE: Dentists are mostly unfamiliar with ultrasonography and ultrasound and their potential uses. This review maps the diagnostic and therapeutic applications of ultrasonography and ultrasound technology in dentistry and highlights the current challenges, gaps of knowledge, and research status of ultrasound technology in this regard.

The Effect of Intensity-Modulated Radiotherapy to the Head and Neck Region on the Oral Innate Immune Response and Oral Microbiome: A Prospective Cohort Study of Head and Neck Tumour Patients.

Neutrophils, also known as polymorphonuclear leukocytes (PMNs), form a significant component of the innate host response, and the consequence of the interaction between the oral microbiota and PMNs is a crucial determinant of oral health status. The impact of radiation therapy (RT) for head and neck tumour (HNT) treatment on the oral innate immune system, neutrophils in particular, and the oral microbiome has not been thoroughly investigated. Therefore, the objective of this study was to characterize RT-mediated changes in oral neutrophils (oPMNs) and the oral microbiome in patients undergoing RT to treat HNTs. Oral rinse samples were collected prior to, during and post-RT from HNT patients receiving RT at Dental Oncology at Princess Margaret Cancer Centre. The oPMNs counts and activation states were analysed using flow cytometry, and the oral microbiome was analysed using 16S rRNA gene sequencing. Statistically significant (p < 0.05) drops in oPMN counts and the activation states of the CD11b, CD16, CD18, CD64 and H3Cit markers from pre-RT to post-RT were observed. Moreover, exposure to RT caused a significant reduction in the relative abundance of commensal Gram-negative bacteria and increased the commensal Gram-positive microbes. Ionizing radiation for the treatment of HNTs simultaneously decreased the recruitment of oPMNs into the oral cavity and suppressed their activation state. The oral microbiome composition post-RT was altered significantly due to RT which may favour the colonization of specific microbial communities unfavourable for the long-term development of a balanced oral microbiome.

The Outcome of Endodontic Regeneration in a Delayed Replanted Immature Permanent Incisor: A TurboReg Analysis of a Case.

OBJECTIVES: The aim of this case report is to address a delayed replantation and successful regenerative endodontic procedure of an avulsed immature permanent incisor which was confirmed by TurboReg analysis. STUDY DESIGN: In this case, regenerative endodontic procedure was performed on an avulsed tooth with a delayed replantation in a 7 year old boy. In the emergency visit after the avulsion accident in February 2017, the tooth was replanted and one week later regenerative endodontic procedure began. After 17 months follow up, in July 2018, root wall thickness and length increase was confirmed by TurboReg analysis. CONCLUSION: The outcome of this treatment was evaluated by TurboReg analysis which was a remarkable increase in root length and dentinal wall thickness, despite of the delayed replantation. CLINICAL SIGNIFICANCE: This case report helps to add to the literature for treatment plan in avulsion traumatic injuries.

Efficacy and safety of different interventions to accelerate maxillary canine retraction following premolar extraction: A systematic review and network meta-analysis.

Decreasing orthodontic treatment duration is at the forefront of innovation for clinical orthodontics. This network meta-analysis aimed to determine the relative efficacy and safety of treatments for accelerated orthodontic tooth movement (OTM) in patients undergoing extraction of maxillary first premolars followed by canine retraction in any orthodontic setting. MEDLINE, EMBASE, Cochrane CENTRAL, CINAHL and SCOPUS were searched (from inception to 20 April 2020). Study selection and data extraction were performed in duplicate. Eligible randomized controlled trials (RCTs) were meta-analysed to estimate the rate of tooth movement, 95% credible interval and surface under the cumulative ranking curve (SUCRA) in the first 3 months following the application of the adjunctive accelerative method. Eligible RCTs were assessed by Cochrane risk of bias tool, and quality of evidence was assessed by GRADE approach, obtained from CINeMA web application. Interventions were ranked for efficacy and reviewed for safety. Nineteen studies pertaining to eight interventions, with data from 415 patients were included. Quality of evidence was very low to moderate. Very low-to low-quality evidence suggests that corticotomy is an efficacious and safe adjunctive treatment to accelerate OTM in comparison with conventional treatment in the first 2 months of treatment. Low-quality evidence suggests that piezocision and micro-osteoperforations (MOP) are efficacious and safe adjunctive treatments only in the first month of treatment. Frequent MOP in conjunction with low-level laser therapy appeared to be an efficacious and safe adjunctive treatment only in the first month following its initial application but not thereafter.

What non-clinical factors influence the general dentist-specialist relationship in Canada?

BACKGROUND: The general dentist-specialist relationship is important for effective patient care and the professional environment. This study explores the non-clinical factors that may influence the general dentist-specialist relationship in Canada. METHODS: A cross-sectional web-based survey of a sample of general dentists across Canada was conducted (N ≈ 11,300). The survey collected information on practitioner (e.g., age, gender, years of practice) and practice (e.g., location, ownership) factors. Two outcomes were assessed: not perceiving specialists as completely collegial and perceiving competitive pressure from specialists. Binary and multivariable logistic regression analysis was conducted. RESULTS: A total of 1328 general dentists responded, yielding a response rate of 11.7%. The strongest associations for perceiving specialists as not completely collegial include being a practice owner (OR = 2.15, 95% CI 1.23, 3.74), working in two or more practices (OR = 1.69, 95% CI 1.07, 2.65), practicing in a small population center (OR = 0.46, 95% CI 0.22, 0.94), and contributing equally to the household income (OR = 0.47, 95% CI 0.26, 0.84). The strongest associations with perceiving medium/large competitive pressure from specialists include having a general practice residency or advanced education in general dentistry (OR = 2.00, 95% CI 1.17, 3.41) and having specialists in close proximity to the practice (OR = 2.52, 95% CI 1.12, 5.69). CONCLUSION: Practitioner and practice factors, mostly related to business and dental care market dynamics, are associated with the potential for strained relationships between general dentists and specialists in Canada. This study points to the need for dental professional organizations to openly discuss the current state of the dental care market, as it has important implications for the profession.

Antibiotics Are Recommended, for the Urgent Management of Pulpal- and Periapical-Related Dental Pain and Intraoral Swelling, Only When There Is Systematic Involvement.

ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION: Evidence-based clinical practice guideline on antibiotic use for the urgent management of pulpal- and periapical-related dental pain and intraoral swelling: A report from the American Dental Association. Lockhart PB, Tampi MP, Abt E, et al. J Am Dent Assoc 2019;150(11):906-921.e12. SOURCE OF FUNDING: The American Dental Association. TYPE OF STUDY/DESIGN: Systematic review with meta-analysis of data.

Limited Evidence Suggests Premedication With Corticosteroids May Help Relieve Postoperative Endodontic Pain in Patients With Symptomatic Pulpitis Undergoing Single-Visit Root Canal Treatment.

ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION: Effect of preoperative corticosteroids in patients with symptomatic pulpitis on postoperative pain after single-visit root canal treatment: a systematic review and meta-analysis. Suneelkumar C, Subha A, Gogala D. J Endod 2018; 44(9):1347-54. SOURCE OF FUNDING: Not provided. TYPE OF STUDY/DESIGN: Systematic review with meta-analysis of data.

Interventions for preventing osteoradionecrosis of the jaws in adults receiving head and neck radiotherapy.

BACKGROUND: Osteoradionecrosis (ORN) of the jaws is among the most serious oral complications of head and neck cancer radiotherapy, arising from radiation-induced fibro-atrophic tissue injury, manifested by necrosis of osseous tissues and failure to heal, often secondary to operative interventions in the oral cavity. It is associated with considerable morbidity and has important quality of life ramifications. Since ORN is very difficult to treat effectively, preventive measures to limit the onset of this disease are needed; however, the effects of various preventive interventions has not been adequately quantified. OBJECTIVES: To assess the effects of interventions for preventing ORN of the jaws in adult patients with head and neck cancer undergoing curative or adjuvant (i.e. non-palliative) radiotherapy. SEARCH METHODS: Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 5 November 2019), the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 10) in the Cochrane Library (searched 5 November 2019), MEDLINE Ovid (1946 to 5 November 2019), Embase Ovid (1980 to 5 November 2019), Allied and Complementary Medicine (AMED) Ovid (1985 to 5 November 2019), Scopus (1966 to 5 November 2019), Proquest Dissertations and Theses International (1861 to 5 November 2019) and Web of Science Conference Proceedings (1990 to 5 November 2019). The US National Institutes of Health Ongoing Trials Register (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. SELECTION CRITERIA: We selected randomised controlled trials (RCTs) or quasi-RCTs of adult patients 18 years or older with head and neck cancer who had undergone curative or adjuvant radiotherapy to the head and neck, who had received an intervention to prevent the onset of ORN. Eligible patients were those subjected to pre- or post-irradiation dental evaluation. Management of these patients was to be with interventions independent of their cancer therapy, including but not limited to local, systemic, or behavioural interventions. DATA COLLECTION AND ANALYSIS: Two review authors independently selected trials from search results, assessed risk of bias, and extracted relevant data for inclusion in the review. Authors of included studies were contacted to request missing data. We used standard methodological procedures expected by Cochrane. MAIN RESULTS: Four studies were identified that met pre-determined eligibility criteria, evaluating a total of 342 adults. From the four studies, all assessed as at high risk of bias, three broad interventions were identified that may potentially reduce the risk of ORN development: one study showed no reduction in ORN when using platelet-rich plasma placed in the extraction sockets of prophylactically removed healthy mandibular molar teeth prior to radiotherapy (odds ratio (OR) 3.32, 95% confidence interval (CI) 0.58 to 19.09; one trial, 44 participants; very low-certainty evidence). Another study involved comparing fluoride gel and high-content fluoride toothpaste (1350 parts per million (ppm)) in prevention of post-radiation caries, and found no difference between their use as no cases of ORN were reported (one trial, 220 participants; very low-certainty evidence). The other two studies involved the use of perioperative hyperbaric oxygen (HBO) therapy and antibiotics. One study showed that treatment with HBO caused a reduction in the development of ORN in comparison to patients treated with antibiotics following dental extractions (risk ratio (RR) 0.18, 95% CI 0.43 to 0.76; one trial, 74 participants; very low-certainty evidence). Another study found no difference between combined HBO and antibiotics compared to antibiotics alone prior to dental implant placement (RR 3.00, 95% CI 0.14 to 65.16; one trial, 26 participants; very low-certainty evidence). Adverse effects of the different interventions were not reported clearly or were not important. AUTHORS' CONCLUSIONS: Given the suboptimal reporting and inadequate sample sizes of the included studies, evidence regarding the interventions evaluated by the trials included in this review is uncertain. More well-designed RCTs with larger samples are required to make conclusive statements regarding the efficacy of these interventions.

Surgical Management of Medication-Related Osteonecrosis of the Jaw Is Associated With Improved Disease Resolution: A Retrospective Cohort Study.

PURPOSE: Optimal management approaches for medication-related osteonecrosis of the jaw (MRONJ) using either surgical or nonsurgical approaches remain inconclusive. Our objective was to compare the effects of surgical versus nonsurgical therapy on the resolution of MRONJ. METHODS: We conducted a retrospective review of eligible patients with a diagnosis of MRONJ at Mount Sinai Hospital, Toronto, Ontario, Canada, who either were seen in the outpatient clinic from January 2014 to December 2016 or received major surgical intervention from January 2011 to December 2016. A multivariate logistic regression was conducted to evaluate the effects of surgical therapy on disease resolution. RESULTS: A total of 78 patients were included in this study. Of these, 56 (72%) received surgical therapy. Antiresorptive agents were being taken for the treatment of osteoporosis by 46 patients (82%) in the surgical group compared with 20 nonsurgical patients (91%) (P = .28). The median follow-up period was 15.5 months (interquartile range, 8.0 to 34.3 months) in the surgical group compared with 11.0 months (interquartile range, 8.0 to 20.5 months) in the nonsurgical group (P = .75). Disease resolution occurred in 39 surgical patients (70%) compared with 8 nonsurgical patients (36%). Surgical therapy was associated with disease resolution compared with nonsurgical therapy alone, after adjustment for age, duration of antiresorptive or antiangiogenic therapy, whether the antiresorptive or antiangiogenic agents were used for oncologic purposes, and the stage of MRONJ at initial presentation (adjusted odds ratio, 4.33; 95% confidence interval, 1.28 to 14.60). CONCLUSIONS: Surgical therapy compared with nonsurgical therapy was associated with disease resolution in patients with MRONJ. High-quality evidence of the superiority of any specific surgical approach in the treatment of MRONJ is needed.

A Consolidated Pulp Test System Including Flowmetry, Pulse Oximetry, and Thermometry.

AIM: The aim of this study is to report manufacturing a consolidated pulp test system that includes thermometry, flowmetry, and pulse oximetry. BACKGROUND: The ideal method for the evaluation of pulp vitality should be objective, noninvasive, easy to use, reliable, and painless. Currently, the most commonly used tests (such as electricity, heat, and cold tests) depend on patients' sensibility and are highly subjective. They only measure a neural response and do not indicate the actual biologic status of the pulp. It has, therefore, been suggested that vitality tests such as flowmetry, pulse oximetry, thermometry, and photoplethysmography be used. Some research has been done on these systems; however, their high costs and space need to maintain all of them that have been obstacles to their use. TECHNIQUE: This report describes designing and manufacturing a novel system for evaluating pulp vitality involving the use of three methods (flowmetry, pulse oximetry, and thermometry) combined in a single small system using only two probes. CONCLUSION: The consolidated pulp tests system may be accurate in determining the pulp vitality. However, after clinical use, some changes may be necessary for improvement of the system.

An evidence-based systematic review of the off-label uses of lisinopril.

AIMS: Lisinopril is an angiotensin-converting-enzyme inhibitor that is largely administered for off-label uses. This study aims to provide a comprehensive review of off-label uses of lisinopril to aid physicians to make evidence-based decisions. METHODS: The following bibliographic databases were searched from inception up to 30 March 2017: PubMed, EMBASE, the Cochrane Library, Cochrane Central Register of Controlled Trials, Scopus, Ovid and Proquest. This systematic review sought all randomized trials conducted on adult individuals comparing lisinopril on its off-label uses with alternative drugs or placebos and reported direct or alternative clinical outcomes. Risk of bias assessment by using the Cochrane Collaboration risk-of-bias tool and quality evaluation took place. RESULTS: Included studies demonstrated significant positive effects of lisinopril on proteinuric kidney disease; however, lisinopril caused a slight reduction of glomerular filtration rate (GFR) especially for patients with GFR < 90 ml min-1 . Lisinopril offered better outcomes in comparison to other standard treatments of diabetic nephropathy. Other studies showed positive effects of lisinopril for migraine, prevention of diabetes, myocardial fibrosis, mitral valve regurgitation, cardiomyopathy in patients with Duchenne muscular dystrophy, oligospermia and infertility, and diabetic retinopathy. Conversely, the studies reported that lisinopril was ineffective for five other off-label uses. CONCLUSIONS: The identified studies showed that lisinopril was highly effective for proteinuric kidney disease with a minor but inconsiderable decrease in GFR. Positive effects of lisinopril were demonstrated in seven other off-label uses; however, lisinopril cannot be recommended as the first choice for these until further clinical trials confirm these positive effects.

Validity of a simplified screening instrument for assessing overweight children in a dental setting: a cross sectional study.

BACKGROUND: Obesity, with its rising prevalence among Canadians and its estimated cost of $2 billion annually in Canada, is no longer considered a cosmetic issue, but a major health issue that imposes a great burden on the healthcare system and economy. This cross sectional study aims to evaluate the feasibility of identifying the weight status of 6 to 11 year-old children in a university dental clinic using a simplified overweight screening instrument. METHODS: One hundred sixty eight healthy children were enrolled. Weight and height were measured and overweight/obesity status was assessed using two techniques: 1) the 2007 World Health Organization Body Mass Index (BMI)-for-age reference Tables, 2) simplified overweight screening instrument without BMI calculation. Measures of overall, positive, and negative percent agreement between the two approaches were computed. RESULTS: The children's average weight, height, BMI and BMI z-score were respectively 32.6 ± 9.5 kg, 133.8 ± 10.7 cm, 17.8 ± 3.2, and 0.4 ± 1.0. The overall, positive, and negative percent agreement between the two screening approaches were respectively, 89%, 100%, and 83%. CONCLUSION: This study demonstrated the feasibility and parental acceptance of weight, height and BMI measurement in a dental setting and evidence that supports the validity of a new simplified approach to assess children's weight status without having to compute BMI. TRIAL REGISTRATION: NCT02637752 . Registered 18 December 2015.

Effects of enamel matrix derivative on non-surgical management of peri-implant mucositis: a double-blind randomized clinical trial.

BACKGROUND: Peri-implant diseases have been recognized as being among the ever-increasing complications related to dental implants. The aim of this study was to evaluate the adjunctive use of enamel matrix derivative (EMD) to mechanical debridement (MD) in patients with these conditions in terms of clinical parameters and cytokine levels of peri-implant crevicular fluid (PICF). METHODS: In the present double-blind clinical trial, 46 patients with peri-implant mucositis (PM) were randomly divided into control and test groups. Two different therapeutic protocols, consisting of non-surgical MD alone (control group) and MD with the application of EMD (test group), were considered for the two groups. Clinical parameters [bleeding on probing (BOP) and probing depth (PD)] and sampling from PICF were carried out before treatment and 3 months postoperatively. The levels of IL-6 and IL-17 cytokines in PICF were evaluated by enzyme-linked immunosorbent (ELISA). RESULTS: Three-month post-interventional assay revealed significant improvements in BOP and PD in the test group in comparison to the control group (P < 0.0001). Relative to control, IL-6 and IL-17 levels were reduced significantly (p < 0.05) in the test group compared to the control group. CONCLUSION: Application of EMD can be considered an adjunct to MD in the non-surgical treatment of PM. However, complete recovery was not observed using either treatment approach showing that management of implant-associated disease is still a significant clinical problem.

Use of and Access to Deep Sedation and General Anesthesia for Dental Patients: A Survey of Ontario Dentists.

OBJECTIVE: This study aims to assess barriers to the use of deep sedation/general anesthesia (DS/GA) identified by dentists in Ontario. METHODS: An email invitation to a web-based survey was distributed to all licensed dentists and specialists who have provided an email address to the provincial regulator (n = 5507). Descriptive and regression analyses were performed to explore practice and demographic factors associated with the use of DS/GA. RESULTS: The response rate was 18.3%. A quarter (24.8%) of respondents reported inadequate access to DS/GA. Access was poorest in rural communities and greatest in the Greater Toronto Area (GTA). Overall, 74.5% of dentists indicated that they had used DS/GA in the past 12 months. Use was defined as having provided the service or referred a patient in the past 12 months. Non-use was most likely among general dentists, part-time dentists, dentists > 64 years and dentists in urban locations. Wait times and travel distances were reported as longer for medically complex patients. The most common reasons for non-use of DS/GA were a lack of perceived demand and additional costs to patients. For DS/GA users, the greatest barrier was additional costs to patients. CONCLUSION: Access to DS/GA in Ontario is not uniform; it remains a challenge in rural communities and regions outside the GTA, especially in the north. Use is lowest among general dentists and urban dentists despite adequate access, with dentists' perception of need for DS/GA and cost to the patient acting as major barriers. Education for dentists and better insurance coverage for patients may improve access for these patients.

A Quality Analysis of Systematic Reviews in Dentistry, Part 1: Meta-Analyses of Randomized Controlled Trials.

OBJECTIVES: As the volume of publications in dentistry continues to increase, clinicians are becoming increasingly reliant on systematic reviews and meta-analyses as their primary source of evidence. With an increase in the dependence on dental metaanalyses, it is important to ensure that they are being conducted with as little bias as possible. The objective of this systematic review is to assess the quality of therapeutic meta-analyses of randomized controlled trials (RCTs) on dental-related topics and to analyze how quality has changed over time. METHODS: All relevant studies were searched for through MEDLINE, Embase, PsycINFO, and the Cochrane Library. Title, abstract, and full-text review, as well as data extraction and quality assessment, were all conducted in duplicate. All reviewers used a pilot-tested extraction form that included the AMSTAR checklist to assess quality of systematic reviews. A logit link function ordinal regression was conducted to evaluate quality improvement trends over time. RESULTS: Of the 3832 studies identified, 208 studies were selected for review. Of these, 13% provided an a priori design, 53% screened and extracted data in duplicate, 29% included gray literature, 63% assessed the quality of included studies, and 39% assessed publication bias. As was indicated by the ordinal regression, the quality of meta-analyses, as per the AMSTAR criteria, has increased significantly with time (P < .001). CONCLUSIONS: This investigation illustrates that although the quality of meta-analyses of RCTs has been increasing since the start of the millennium, there remains substantial room for improvement within all aspects of systematic review reporting and methodology. Therefore, it is critical for clinicians to take caution when reading systematic reviews and meta-analyses, ensuring that the principals of critical appraisal are applied when interpreting meta-analyses of RCTs.