Faculty Bibliography

ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION: Antagonistic interactions between sodium hypochlorite, chlorhexidine, EDTA, and citric acid. Rossi-Fedele G, Dovgramaci EJ, Guastalli AR, Steier L, Figueiredo JA. J Endod 2012 Apr;38(4):426-31. REVIEWER: Analia Veitz-Keenan, DDS PURPOSE/QUESTION: To find evidence of the unwanted effects after the chemical combination between sodium hypochlorite, chlorhexidine, and the chelating agents EDTA and citric acid used in endodontic therapy SOURCE OF FUNDING: Information not available TYPE OF STUDY/DESIGN: Literature review LEVEL OF EVIDENCE: Level 3: Other evidence STRENGTH OF RECOMMENDATION GRADE: Grade C: Consensus, disease-oriented evidence, usual practice, expert opinion, or case series for studies of diagnosis, treatment, prevention, or screening.

The dental management of a liver transplant patient requires an awareness of the problems associated with controlling infection, bleeding and pain. Consultation with the patient's physician is most important. Laboratory tests to determine liver function, complete blood count (CBC)-including white blood cells and platelets-and clotting ability (international normalized ratio [INR]) are a necessity. In the case report presented here, the dentist, in consultation with the patient's physician, outlines a dental management plan that includes the need for antibiotic prophylaxis and delineates the types of antibiotics, analgesics and local anesthetics that may be used.

DATA SOURCES: The Cochrane Oral Health Group's Trials Register, CENTRAL, Medline, Embase, and LILACS databases were searched with no restrictions. STUDY SELECTION: Randomised controlled trials (RCTs) involving single or multi-rooted permanent teeth requiring root canal treatment (RoCT) which compared irrigants against each other or against inactive irrigant or placebo were included. Combinations of irrigants were allowed and if used in conjunction with EDTA (ethylenediaminetetra-acetic acid) or similar chelating agents. DATA EXTRACTION AND SYNTHESIS: Two review authors independently assessed risk of bias of included trials and extracted data. RESULTS: Eleven trials (851 participants, 879 teeth) were included. Six trials were assessed at high risk of bias, three unclear and two low. Four compared sodium hypochlorite versus chlorhexidine, the other trials compared different interventions and only two of these trials included useable data on the primary outcomes of swelling and pain. Meta-analysis of sodium hypochlorite versus chlorhexidine indicated no strong evidence of a difference in the existence of bacterial growth between the interventions (risk ratio 0.73; 95% confidence interval 0.34 to 1.56; P = 0.41). None of the included trials reported any data on adverse effects nor radiological changes in periapical radiolucency. CONCLUSIONS: Although root canal irrigants such as sodium hypochlorite and chlorhexidine appear to be effective at reducing bacterial cultures when compared to saline, most of the studies included in this review failed to adequately report these clinically important and potentially patient-relevant outcomes. There is currently insufficient reliable evidence showing the superiority of any one individual irrigant. The strength and reliability of the supporting evidence was variable, and clinicians should be aware that changes in bacterial counts or pain in the early postoperative period may not be accurate indicators of long-term success. Future trials should report both clinician-relevant and patient-preferred outcomes at clearly defined perioperative, as well as long-term, time points.

DESIGN: Randomised controlled trial. INTERVENTION: Participants were randomly assigned to receive either a Hawley retainer (HR) or a clear overlay retainer (COR). The HR was composed of a 2 mm-thick acrylic resin base plate, one-arm clasps with 0.9 mm-diameter stainless steel wire on the first molars, and a Hawley bow with 0.7 mm stainless steel wire. The COR was made from a 0.75 mm-thick thermoplastic material with the buccal edge paralleling the gingival margin, the lingual portion extending 4 to 5 mm beyond the lingual gingival margin. Distally the second molars were covered. Both groups of patients were required to wear the retainers full-time, except during meals and were followed for one year. OUTCOME MEASURE: Retainer survival was the primary outcome. Small surface cracks were not considered as a breakage unless the retainers could not be worn because of crack expansion. RESULTS: One hundred and twenty patients were randomised, 61 in the HR group, 59 in the COR group, nine patients (five in the HR group and four in the COR group) were lost to follow up. Fracture was the most often cited reason for breakage, followed by retainer loss. No significant differences were seen in survival times between the two groups. Both retainers tended to fracture, but the fracture locations were different. CONCLUSIONS: This analysis suggests that the survival times of the HRs and CORs were not statistically significantly different. Therefore, clinicians could advise their patients to wear either of the two retainers without taking breakage into consideration.

DESIGN: Randomised controlled trial. INTERVENTION: Patients were randomised to receive either a 5 g tube of dexamethasone ointment (containing 5 mg dexamethasone) [n=120] or placebo ointment [n=120]. Participants were instructed to apply the given agents to the ulcer three times a day (after meals) for five days. The initial application of the medication was performed under observation for >30 minutes for any signs of adverse effects. Patients kept a daily log and were reviewed clinically on day 6 +/- 2. OUTCOME MEASURE: The size, pain level, healing ratio, average duration of ulcers and the safety of the agents were evaluated. The serum concentration of dexamethasone was monitored. RESULTS: After 6 +/- 2 days of treatment, there was significant difference in the ulcer size between the treatment group (7.167+/- 6.3415 mm(2)) and the control group (4.346 +/- 7.0666 mm(2); P=.000), and in the variation of pain level between the treatment group (5.623+/- 1.9570) and the control group (4.940+/- 2.2449; P=.001). The healing ratio was 83.33% in the treatment group and 54.70% in the control group (P=.000). No severe adverse reactions were observed. No serum dexamethasone was detected before or after the use of the agents (<0.502 ng/mL). CONCLUSIONS: The current study revealed that dexamethasone ointment was safe and efficient in reducing ulcer size, alleviating ulcer pain and hastening ulcer healing in patients with recurrent aphthous ulceration. In addition, the patients had a good overall assessment of the agents. We could not detect dexamethasone in the serum of patients, which illustrated further the safety of dexamethasone ointment.

BACKGROUND: Members of the practice-based research network Practitioners Engaged in Applied Research and Learning (PEARL) Network investigated the dentin caries activity in early occlusal lesions and its relationship to patient age, preoperative tooth sensitivity and radiographic appearance, as well as its influence on preparation depth and volume. METHODS: PEARL Network practitioner-investigators (P-Is) (n = 45), general dentists who were trained but whose methods were not calibrated, conducted a study regarding postoperative hypersensitivity in resin-based composite restorations. The P-Is enrolled as study participants 613 patients with occlusal carious lesions that, in the P-Is' clinical judgment, required restoration. The P-Is used baseline radiographs to assess the depth and extent of the lesions. Data for 671 restorations included baseline sensitivity; ranking of dentin caries activity on the opening of the enamel; radiographic visibility (n = 652); and measurements of preparation depth, width and length. RESULTS: P-Is found rapidly progressing dentin caries in 38.5 percent (258 of 671) of lesions and slowly progressing (and potentially inactive dentin) caries in the remainder of the lesions. Rapidly progressing caries was not related to the participant's age or participant-reported preoperative hypersensitivity but was related to the lesion depth as seen radiographically (P < .001) and depth (P < .001) and volume (P < .001) of the preparation. Molars had slightly higher but not statistically significant levels of caries activity. CONCLUSION: Rapidly progressing dentin caries, while present in only 38.5 percent of lesions, was related to the lesion's radiographic appearance but not to the participant's age or the study tooth's pre-operative sensitivity. CLINICAL IMPLICATIONS: On the basis of the low level of rapidly progressing dentin caries in this study population and the fact that slowly progressing caries can be inactive or remineralizing, the authors advise sealing versus operative treatment of early or shallow occlusal lesions.

Data sourcesThe Cochrane Oral Health Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL), Medline and Embase databases were searched with no restrictions regarding language or date of publication. Bibliographies of identified publications were also checked for relevant studies, and authors were contacted to identify missing and unreported trials. The WHO International Trials Registry Platform was searched for ongoing studies, using the term 'oral lichen planus'.Study selectionRandomised controlled clinical trials (RCTs) of therapy for symptomatic OLP which compared treatment with a placebo or between treatments or no intervention were considered for this review.Data extraction and synthesisThe titles and abstracts of all reports identified were scanned independently by two review authors. All studies meeting the inclusion criteria were assessed for risk of bias and data were extracted. For dichotomous outcomes, the estimates of effects for the intervention were expressed as risk ratios (RR) together with 95% confidence intervals. For continuous outcomes, mean differences (MD) and 95% confidence intervals were used to summarise the data. Meta-analyses were conducted for studies with similar comparisons reporting the same outcome measures.ResultsTwenty-eight trials were included. Although topical steroids are considered first line treatment for symptomatic OLP, we identified no RCTs that compared steroids with placebo. There is no evidence from the three trials of pimecrolimus that this treatment is better than placebo in reducing pain from OLP. There is weak evidence from two trials, at unclear and high risk of bias respectively, that aloe vera may be associated with a reduction in pain compared to placebo, but it was not possible to pool the pain data from these trials. There is weak and unreliable evidence from two small trials, at high risk of bias, that cyclosporin may reduce pain and clinical signs of OLP, but meta-analysis of these trials was not possible.There were five trials that compared steroids with calcineurin inhibitors, each evaluating a different pair of interventions. There is no evidence from these trials that there is a difference between treatment with steroids compared to calcineurin inhibitors with regard to reducing pain associated with OLP. From six trials there is no evidence that any specific steroid therapy is more or less effective at reducing pain compared to another type or dose of steroid.ConclusionsFrom the 28 trials included in this systematic review, the wide range of interventions compared means there is insufficient evidence to support the effectiveness of any specific treatment as being superior