Faculty Bibliography

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

Data sourcesThe review searched for published and ongoing trials in several databases with no restrictions on language or date of publication which included the Cochrane Oral Health Group Trials, Central Register of Controlled Trials, Medline, CINAHL, Embase, WHO Clinical Trials Registry Platform and clinical trial.gov.Study selectionRandomised clinical trials were considered that evaluated any intervention compared with another or with placebo for treating postoperative bleeding (PEB), post extraction. The primary outcome measures sought were: bleeding, amount of blood loss and cessation time required to control bleeding. The secondary outcomes: patient reported outcomes, such as pain or discomfort and adverse events.Data extraction and synthesisThree pairs of review authors independently screened the records.ResultsThe search strategy identified 1526 articles and abstracts. After removal of duplicates, 943 records were screened. Thirty-four full texts were examined. No trials met the inclusion criteria for the review.ConclusionsWe were unable to identify any reports of randomised controlled trials that evaluated the effects of different interventions for the treatment of post-extraction bleeding. In view of the lack of reliable evidence on this topic, clinicians must use their clinical experience to determine the most appropriate means of treating this condition, depending on patient-related factors. There is a need for well designed and appropriately conducted clinical trials on this topic, which conform to the CONSORT statement (www.consort-statement.org/).

Data sourcesRelevant databases were searched for the review such as the Cochrane Oral Health Group Trials Register, Medline, EMBASE, clinical trials.gov, WHO International Clinical Trials Registry Platform.Study selectionRandomised controlled trials comparing adhesively bonded versus non-bonded class I and II amalgam restorations in permanent molars and premolars.Data extraction and synthesisTwo reviewers independently screened papers and extracted data.ResultsOne trial with 31 patients who received 113 restorations was included. At two years, 50 out of 53 restorations in the non-bonded group survived and 55 of 60 restorations survived with five unaccounted for at follow-up. Post insertion sensitivity was not statistically significant at baseline and for the two-year follow-up. No fractures or differences in the marginal adaptation were reported.ConclusionsThere is no evidence either to claim or to refute a difference in survival between bonded and non-bonded amalgam restorations. In view of the lack of evidence on the additional benefit of adhesively bonding amalgam in comparison with non-bonded amalgam, it is important that clinicians be mindful of the additional costs that may be incurred.

Data sourcesMedline and Embase databases and bibliographies of all included articles and relevant review articles were screened for possible inclusion.Study selectionLongitudinal studies were included reporting on implant survival, success, incidence of peri-implantitis, bone loss and periodontal status and on partially dentate patients with a history of treatment for periodontitis. There were no language restrictions for the included studies.Data extraction and synthesisAuthors independently and in duplicate assessed the studies for eligibility and data extraction. Disagreements were resolved by discussion and consensus. The methodological quality assessment of the included studies was done using an adapted Newcastle-Ottawa Scale (NOS). Confounding factors such as smoking, systemic disease influencing osseointegration, chemotherapy and radiation were assessed and adjusted in the analysis. Data were organised into tables and grouped in accordance with the study design.ResultsTwenty-four studies reported in 27 publications were included. Implant survival and success rate were higher in periodontally healthy patients.Twelve prospective cohort studies, five case series with a control group, four retrospective cohort studies and three studies with a sub group comparison were included.Bone loss and peri-implantitis were increased in patients with a history of treated periodontitis. More complications were reported in patients presenting with more severe forms of periodontitis. High heterogeneity among the studies in terms of study design, population, therapy, unit of analysis, inconsistent definitions of baseline and outcomes, inadequate reporting and confounding factors meant a meta-analysis could not be performed.Most of the studies showed better implant survival rates for the non-periodontitis group ranging from 91.67% to 100% compared to the treated periodontitis group 79.22% to 100% over a 1.2 to 16 year follow-up.ConclusionsImplants placed in patients treated for periodontal disease are associated with higher incidence of biological complications and lower success and survival rates than those placed in periodontally healthy patients. Severe forms of periodontal disease are associated with higher rates of implant loss. The conclusion of the review is limited by the strength of the evidence.

Data sourcesA broad computerised search with similar key terms was performed in different databases that included: Ovid Medline, Thomson's ISI Web of Science, PubMed, Science Direct, EMBASE and the Cochrane Library. Grey literature, dissertations, abstracts and theses were searched too. Reference lists of the selected articles were hand-searched.Study selectionThe inclusion criteria included in vivo randomised clinical trials and quasi-randomised clinical trials using gingival retraction techniques with and without cord. Studies were included if they examined the primary outcome from the review: efficiency of haemostasis control, the amount of gingival displacement and the influence of the techniques on gingival/periodontal health. Secondary outcomes accepted for the review included subjective factors reported by the patient such as pain, sensitivity, unpleasant taste and discomfort and operator's experience with both techniques. Non-English papers, clinical reports, animals studies or in vitro studies were excluded.Data extraction and synthesisTwo authors independently searched and screened the articles. Disagreements were resolved by discussion. A third reviewer participated in the eligibility of the studies. The risk of bias was assessed using the Cochrane Collaboration tool. Due to the heterogeneity of measurement variables across the studies and the differences among the studies, a meta-analysis was not performed. A narrative assessment was performed for the outcomes: moisture/bleeding control, gingival displacement, gingival/periodontal health and the subjective outcomes.ResultsFrom the initial search that retrieved 1,342 articles, 19 potential relevant full-text articles were considered for the review. Seven studies were selected for the systematic review. Four randomised clinical trials were included. Sample size ranged from eight to 252 participants per study. Five studies were conducted on patients requiring any indirect fixed restorations on prepared teeth. Two studies were done on unprepared teeth. In all studies, participants were in good health, had a healthy gingival condition and a sound periodontal status.ConclusionsBoth techniques are reliable in achieving gingival retraction. The review supports the observation that gingival retraction paste can more effectively help to achieve a dry field and at the same time be less injurious to soft tissues, however its ability to displace gingival tissues, compared to retraction cord, was compromising. Rather than considering the cost of material or the individual preference of the operator, choosing the right technique to maximise clinical efficiency should be based on scientific evidence. It seems that impregnated gingival cords are more effective on thick gingival tissue whereas paste is more effective when minimal retraction is required for haemostasis control, preservation of the gingiva and less tissue displacement.

OBJECTIVE: Dental treatment is often categorized as a moderately or severely painful experience; however, no clinical data reported by the patient and dentist currently exists to support this degree of pain. This has contributed possibly to the overprescribing of analgesics, in particular the opioid class of medications. The primary objective of the study was to document the dentists' postprocedural prescriptions and recommendations for analgesic medications and their effectiveness for a 5-day period. Medications prescribed or recommended in the patient-reported outcomes included: opioid, nonsteroidal anti-inflammatory drugs (NSAIDs), and over-the-counter (OTC) analgesics. Met hods : This study used both dentist and patient responses to evaluate the use of opioid, NSAID, and OTC recommended or prescribed analgesics following one of seven classes of dental procedures encompassing over 22 specific coded procedures thought to elicit pain. The patient-centered study included a 5-day postprocedural patient follow-up assessment of the medication's effectiveness in relieving pain. RESULTS: Baseline questionnaires were completed by 2765 (99.9%) of 2767 eligible patients, and 2381 (86%) patients responded to the Day 5 follow-up questionnaires. CONCLUSION: The data suggest NSAIDs, both OTC and prescribed dosages, may be a sufficient analgesic to treat most postoperative dental pain. Clinical judgment as to the use of an opioid should include the physiological principles related to the pharmacology of pain and inflammation and may include a central effect. ClinicalTrials.gov Identifier: NCT02929602.

Data sourcesMedline, Embase, Cochrane Central and grey literature, complemented by cross-referencing from bibliographies. Diagnostic reviews were searched using the Medion database.Study selectionStudies reporting on the accuracy (sensitivity/specificity) of radiographic detection of primary carious lesions under clinical (in vivo) or in vitro conditions were included. The outcome of interest was caries detection using radiographs. The study also assessed the effect of the histologic lesion stage and included articles to assess the differences between primary or permanent teeth, if there had been improvements recently due to technical advances or radiographic methods, or if there are variations within studies (between examiners or applied radiographic techniques).Data extraction and synthesisData extraction was done by one reviewer first, using a piloted electronic spreadsheet and repeated independently by a second reviewer. Consensus was achieved by discussion. Data extraction followed guidelines from the Cochrane Collaboration. Risk of bias was assessed using QUADAS-2. Pooled sensitivity, specificity and diagnostic odds ratios (DORs) were calculated using random effects meta-analysis. Analyses were performed separately for occlusal and proximal lesions. Dentine lesions and cavitated lesions were analysed separately.Results947 articles were identified with the searches and 442 were analysed full text. 117 studies (13,375 teeth, 19,108 surfaces) were included. All studies were published in English. 24 studies were in vivo and 93 studies were in vitro. Risk of bias was found to be low in 23 and high in 94 studies. The pooled sensitivity for detecting any kind of occlusal carious lesions was 0.35 (95% CI : 0.31/40) and 0.41 (0.39/0.44) in clinical and in vitro studies respectively while the pooled specificity was 0.78 (0.73/0.83) and 0.70 (0.76/0.84). For the detection of any kind of proximal lesion the sensitivity in the clinical studies was 0.24 (CI 0.21/0/26) and 0.43 (0.41/0.45) and the specificity was 0.97 (0.95/0.98) and 0.89 (0.88/0.90).With regard to the dentine lesions the sensitivities were 0.36 (0.24-0.49) for proximal to 0.56 (0.53-0.59) for occlusal lesions and specificities ranged between 0.87 (0.85-0.89) and 0.95 (0.94-0.96). No reports were found for cavitated occlusal lesions. For proximal lesions sensitivities were above 0.60 and sensitivities above 0.90. Diagnostic Odds Ratios (DOR) were >1 (indicates a useful test) and were higher in proximal than in occlusal lesions. The DOR calculated for proximal lesions in vitro studies was 16.0 (11.5/22.4) and DOR 7.5 (3.4/16.5) for clinical studies). Heterogeneity calculated using I(2) test was moderate: > 50-67%.ConclusionsCaries detection determined by dental radiographs is highly accurate for proximal lesions and dentine caries lesions. For initial carious lesions the test needs to be used with other more sensitive methods in populations that present with high caries risk.

DATA SOURCES/METHODS:Electronic searches were undertaken in PubMed/Medline, Web of Science, Cochrane Oral Health Group Trials Register as well as hand searching. STUDY SELECTION/METHODS:Clinical human studies, either randomised or not, providing outcome data for dental implant failure in smokers and non-smokers in any group of patients with no follow-up restrictions. Patients smoking a minimum of one cigarette a day were classified as smokers and implant failure was considered as the complete loss of the implant.Data extraction and synthesisThree authors independently participated in the inclusion criteria and disagreements were resolved by discussion. Quality assessment of the studies was performed using a scale to appraise observational studies. From the selected studies, data were extracted when available which included year of publication, study design, country, setting, number of patients, type of smokers, age, follow-up, days of antibiotic prophylaxis, failure, postoperative infection, marginal bone loss, implant surface, dental arch receiving implants, type of prosthetic rehabilitation and opposing dentition. For the meta-analysis, implant failure and postoperative infection were evaluated as dichotomous outcomes, while weighted mean differences were used for marginal bone loss as a continuous outcome. The statistical unit was the implant. Heterogeneity was calculated using I(2) test. RESULTS:From 1432 records identified, 107 publications were included in the review for the qualitative and quantitative synthesis. One hundred and four studies compared implant failure rates. From the total studies, the authors judged 85 to be of high quality and 22 of moderate quality. The meta-analysis for failure rate resulted in a statistically significant overall result of risk ratio (RR) of 2.23 (95% CI 1.96-2.53) heterogeneity of I(2): 51%. The meta-analysis of four studies evaluating the risk of postoperative infections in smokers presented a statistically significant result with an RR: 2.01, 95% CI 1.09-3.72, heterogeneity I(2): 0%, and the marginal bone loss had an overall statistically significant difference of MD 0.32, 95% CI 0,21-043; heterogeneity in this case was I(2): 95%. CONCLUSIONS:The insertion of implants in smokers affected the failure rates, the risk of postoperative infections, as well as the marginal bone loss. The results should be interpreted with caution due to the presence of uncontrolled confounding factors in the included studies.

Data sourcesA comprehensive search was carried out on major databases such as PubMed, EMBASE and Cochrane CENTRAL. Reference lists of the included studies were explored along with journals likely to contain studies relevant to the topic. The search was restricted to the English languageStudy selectionThe inclusion criteria included randomised and quasi-randomised controlled trials including parallel or cross-over studies comparing botulinum toxin therapy (BTX) versus any alternative intervention or placebo.Data extraction and synthesisQuality assessment and data extraction were done following the Cochrane risk of bias tool and recommendations. All of the steps in the review, including the search and selection process, were done independently by two reviewers. Disagreements were discussed with one another until consensus was reached.ResultsFive relevant studies were included in the review, which consisted of 117 participants. Two trials revealed a significant inter-group difference in myofascial pain reduction. Another trial that compared BTX with fascial manipulation showed no significant difference in pain relief for temporomandibular disorders (TMDs), while the remaining two trials showed no significant difference between the BTX and placebo groups. Meta-analysis was not performed due to the considerable variation in study methods and evaluation of the results. All five studies were targeted primarily on the masseter and temporalis muscles and most of them administered injections at bilateral muscle sites. The methods used to find the muscles to target were all based on physical examination, with three studies using electromyography (EMG) as guidance. The dose of BTX ranged from 70U to 300U, the majority used being 100-150U. All studies gave a single session of BTX and re-evaluated participants at least one month following the injection.ConclusionsNo consensus could be reached on the therapeutic benefit of BTX on TMDs.

Data sourcesCochrane Oral Health Groups Trial Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE via OVID and EMBASE via OVID. Databases were searched with no language or date restrictions.Study selectionTwo authors independently reviewed the titles and the abstracts for inclusion. Disagreements were resolved by discussion. If needed, a third author was consulted. Included were randomised clinical trials with a follow-up of at least three months which evaluated the use of prophylactic antibiotic compared to no antibiotic or a placebo and examined different antibiotics of different doses and durations in patients undergoing dental implant placement. The outcomes were implant failure (considered as implant mobility, removal of implant due to bone loss or infection) and prosthesis failure (prosthesis could not be placed).Data extraction and synthesisStandard Cochrane methodology procedures were followed. Risk of bias was completed independently and in duplicate by two review authors. Results were expressed as risk ratios (RRs) using a random-effects model for dichotomous outcomes with 95% confidence intervals (CI). The statistical unit was the participant and not the prosthesis or implant. Heterogeneity including both clinical and methodological factors was investigated.ResultsSix randomised clinical trials with 1162 participants were identified for the review. Three trials compared 2 g of preoperative amoxicillin versus placebo (927 participants). One trial compared 3 g of preoperative amoxicillin versus placebo (55 participants). Another trial compared 1 g of preoperative amoxicillin plus 500 mg four times a day for two days versus no antibiotic (80 participants). An additional trial compared four groups: (1) 2 g of preoperative amoxicillin; (2) 2 g of preoperative amoxicillin plus 1 g twice a day for seven days; (3) 1 g of postoperative amoxicillin twice a day for seven days and (4) no antibiotics (100 participants). The overall body of the evidence was considered moderate.The meta-analysis of the six trials showed a statistically significant higher number of implant failures in the group not receiving antibiotics, RR= 0.33 (95% CI; 0.16 to 0.67) P = 0.0002.The number needed to treat for one additional benefit outcome (NNTB) to prevent one person having an implant failure is 25 (95% CI; 14 to 100) based on an implant failure of 6% in participants not receiving antibiotics.There was borderline statistical significance for prosthesis failures (RR= 0.44 (95%CI; 0.19 to 1.00) with no statistically significant differences for infections or adverse events. No conclusive information for the different durations of antibiotics could be determinedConclusionsThere is statistically significant evidence suggesting that a single dose of 2 g or 3 g of amoxicillin given orally is beneficial in reducing dental implant failure in ordinary conditions. No significant adverse events were reported. It is still unknown whether post-operative antibiotics are beneficial and which antibiotic is more effective.