Does an interim dressing with calcium hydroxide reduce endotoxins between endodontic appointments?

Data sources PubMed, Cochrane Library, LILACS/Biblioteca Brasileira de Odontologica, Web of Science, Embase, Scopus, grey literature.Study selection Randomised and non-randomised clinical studies, experimental studies. Population: human studies with permanent dentition; Intervention: evaluation of lipopolysaccharide (LPS) after dressing with calcium hydroxide (CH); Comparison: evaluation of LPS before dressing with CH; Outcome: antimicrobial efficacy against LPS.Data extraction and synthesis A modified Cochrane Risk of Bias (RoB) tool was used to evaluate internal validity of randomised controlled trials, Robins-1 tool for non-randomised controlled trials, and the 'Before and After' tool for experimental studies. Meta-analyses were conducted by subgrouping according to CH use, chemo-mechanical preparation (CMP), antimicrobial substance (AS), and irrigant. Further analyses explored incidence of LPS reduction. All subgroups were assessed for heterogeneity through I2 test and the random-effect model was applied. Sensitivity analysis was performed to evaluate the influence of studies with RoB in effect significance.Results Nine studies were included for qualitative assessment, of which seven were included for meta-analysis. Three studies were assessed as low RoB, one was medium risk, with two having a high RoB. Three studies presented with 'some concerns'. After dressing with CH, no AS resulted in 61.7% of teeth with reduction in LPS (95% CI: 37.7%-82.9%, I2 = 96.7%), compared to AS where 98.9% of teeth showed an LPS reduction (95% CI: 97.4%-99.8%, I2 = 38.6%). Where mean reductions in LPS were compared, CH with or without AS, reduced mean LPSs before (standardised mean difference [SMD] = 21.087 [CI: 21.453 to 20.721], P = 0.001, I2 = 58.7%) and after CMP (SMD = 20.919 [CI: 21.156 to 20.682], P = 0.001, I2 = 24.7%) using a CH dressing. Considering the irrigant solutions, the overall results showed a reduction before (SMD = 21.053 [CI: 21.311 to 20.795], P = 0.001, I2 = 58.7%) and after CMP (SMD = 20.938 [CI: 21.147 to 20.729], P = 0.001, I2 = 24.6%) using a CH dressing. There was a reduction in mean LPS over time, up to 30 days. All analyses presented a very low certainty of evidence.Conclusions An interim dressing with CH reduces LPS levels below those achieved with CMP and AS, but does not eliminate LPS completely. No evidence is presented on improved clinical outcomes following multiple-visit treatment with CH dressing.

Effect of topical neuromodulatory medications on oral and skin keratinocytes.

BACKGROUND: Neuromodulatory medications (NMs), such as amitriptyline, carbamazepine and gabapentin, are used as topical preparations for the management of neuropathic orofacial pain (NOP) and have produced promising preliminary results. The aim of this study was to investigate the effects of three aforementioned NMs on cell lines relevant to the orofacial tissues in vitro as no published studies have examined the effect of these topical NMs. METHODS: Cellular viability was measured using alamarBlue® , testing cumulative and specific time point effects of NMs on human skin keratinocytes and oral keratinocytes. Effects of the NMs on cell counts were investigated by CCK-8 assay. Drug concentrations released from NM orabase pastes after 30-min incubation were measured by high-performance liquid chromatography. Using these clinical concentrations, morphological changes and cytokine expression were investigated using scanning electron microscopy (SEM) and human inflammatory antibody array (AAH), respectively. RESULTS: Cumulative and specific time point viability and cell count methods revealed that amitriptyline caused a significant decrease in cellular viability and counts in both cell lines. Carbamazepine also had significant effects after long-term exposure and at higher concentrations, whilst gabapentin had little demonstrable effect. SEM confirmed the cytotoxicity of amitriptyline, whilst AAH revealed no significant changes in cytokine expression following amitriptyline, carbamazepine or gabapentin exposure compared with control. CONCLUSIONS: The results raise concerns about the safety of topical amitriptyline as it was cytotoxic to skin and oral keratinocytes in both exposure times and concentrations, whilst carbamazepine was cytotoxic only at high concentrations and after longer exposure times and gabapentin had no demonstrable effects.

Determination of the mental foramen position in dental radiographs in 18-30 year olds.

OBJECTIVES: To determine the radiographic position and reliability of assessing mental foramen (MF) position in relation to premolar crowns in an 18- to 30-year-old UK-based population. METHODS: Following ethical approval and a power calculation, the position of the MF was recorded in relation to premolar crowns and apices in 100 dental panoramic tomographs. Positions were assessed by three senior clinicians independently, then by consensus. Data were analysed using descriptive statistics, χ(2) and Fleiss' and Cohen's kappa. RESULTS: Reliability data showed only fair to moderate agreement on independent scoring. Substantial to almost perfect agreement was achieved by consensus, demonstrating the most common position for the MF to be between the first and second premolar teeth when using both premolar crowns (51%) and apices (76%) as reference points. There was a significant difference in the position of the foramen between the left and right sides (p < 0.05), with only 62% of cases showing symmetry. CONCLUSIONS: The most common position for the MF is between the first and second premolar teeth; however, anatomical variation is seen. Use of pre-operative radiographs to relate the position of the MF to premolar crowns may not be reliable.

Factors affecting patient valuations of caries prevention: Using and validating the willingness to pay method.

OBJECTIVES: Determining the value of, or strength of preference for health care interventions is useful for policy makers in planning health care services. Willingness to pay (WTP) is an established economic technique to determine the strength of preferences for interventions by eliciting monetary valuations from individuals in hypothetical situations. The objective of this study was to elicit WTP values for a dental preventive intervention and to analyze the factors affecting these as well as investigating the validity of the WTP method. METHODS: Patients aged 40 years plus attending dental practices in the UK and Germany were recruited on a consecutive basis over one month. Participants received information about a novel root caries prevention intervention. They then completed a questionnaire including a WTP task. Where the coating was indicated, patients were offered this for a payment and acceptance was recorded. Analysis included econometric modelling and comparison of expected (based on stated WTP) versus actual behaviour. RESULTS: The mean WTP for the coating was £96.41 (standard deviation 60.61). Econometric models showed that no demographic or dental history factors were significant predictors of WTP. 63% of the sample behaved as expected when using stated WTP to predict whether they would buy the coating. The remainder were split almost equally between those expected to pay but who did not and those who were expected to refuse but paid. CONCLUSIONS: Values for a caries preventive intervention had a large and unpredictable variance. In comparing hypothetical versus real preferences both under- and over-valuation occurs. CLINICAL SIGNIFICANCE: Wide and unpredictable variation in valuations for prevention may mean that there are difficult policy questions around what resource should be allocated to dental prevention and how to target this resource.

Biodentine and mineral trioxide aggregate induce similar cellular responses in a fibroblast cell line.

INTRODUCTION: The aim of this study was to assess the cell viability and messenger RNA expression of interleukin (IL)-1α and IL-6 in 3T3 fibroblast cells when in direct contact with Biodentine (Septodont, Saint Maur de Fossés, France) and mineral trioxide aggregate (MTA). METHODS: Biodentine and MTA were coated onto coverslips and allowed to set. An uncoated coverslip and one coated with GC Fuji IX (GC Corporation, Tokyo, Japan) were used as controls. Coverslips were cultured with 3T3 fibroblast cells. Cell viability was assessed quantitatively using AlamarBlue dye (Serotec, Oxford, UK) after 3, 6, 24, and 72 hours. Morphologic cell changes of 3T3 cells in contact with BD and MTA were observed by scanning electron microscopy, and cytokine expression was assessed at the messenger RNA level by semiquantitative reverse-transcription polymerase chain reaction after 3 and 24 hours of direct contact with the materials. RESULTS: Cells in contact with Biodentine and MTA showed similar viability to untreated control cells at all time points, with the exception of 6 hours when viability was decreased with both treatments. Examination by scanning electron microscopy revealed cells adhering to most of the Biodentine surface after 24 hours. However, for MTA samples, significantly fewer cells were observed. The messenger RNA expression of IL-1α and IL-6 by cells in contact with Biodentine was similar to cells in contact with MTA. CONCLUSIONS: Biodentine and MTA showed similar cytotoxicity and induced a similar pattern of cytokine expression.

Is mandibular molar buccal infiltration a mental and incisive nerve block? A randomized controlled trial.

INTRODUCTION: The aim of this study was to compare the efficacies of buccal local anesthetic infiltrations at various sites of the mandible in order to elucidate the mechanism of action of articaine mandibular infiltrations. METHODS: After a power calculation and ethical approval, 22 volunteers received 1.8 mL 4% articaine hydrochloride with 1:100,000 adrenaline as a buccal infiltration at the canine, first, or second molar in a randomized, double-blind, crossover design. The injections at the canine and first molar were considered equidistant from the mental foramen. Responses of the first and second molars, first premolar, and lateral and central incisors were assessed using an electronic pulp tester over a 47-minute period. Volunteers were asked to rate the discomfort of each injection using a visual analog scale. Data were analyzed using repeated measures analysis, McNemar, and Mann-Whitney U testing. RESULTS: Injections at the canine and first molar teeth produced anesthesia in all teeth tested in some volunteers. There was no significant difference between anesthetic success of the first premolar after infiltration at the canine or the first molar. Injection at the second molar failed to produce anesthesia of the incisor teeth. Anesthesia was significantly more likely after injections at an adjacent site. There was no difference in discomfort associated with injections at different sites of the mandible. CONCLUSIONS: Articaine first mandibular molar infiltrations achieve an effect via a combination of modified mental and incisive nerve block and local infiltration. Infiltration at the second molar produces anesthesia of both molar and premolar teeth, primarily via infiltration.

A prospective randomized trial of different supplementary local anesthetic techniques after failure of inferior alveolar nerve block in patients with irreversible pulpitis in mandibular teeth.

OBJECTIVE: The objective of this study was to compare the efficacy of supplementary repeat inferior alveolar nerve block with 2% lidocaine and epinephrine, buccal infiltration with 4% articaine with epinephrine, intraligamentary injection, or intraosseous injection (both with 2% lidocaine with epinephrine) after failed inferior alveolar nerve block (IANB) for securing pain-free treatment in patients experiencing irreversible pulpitis in mandibular permanent teeth. METHODS: This randomized clinical trial included 182 patients diagnosed with irreversible pulpitis in mandibular teeth. Patients received 2.0 mL of 2% lidocaine with 1:80,000 epinephrine as an IANB injection. Patients who did not experience pain-free treatment received randomly 1 of 4 supplementary techniques, namely repeat lidocaine IANB (rIANB), articaine buccal infiltration (ABI), lidocaine intraligamentary injection (PDL), or lidocaine intraosseous injection (IO). Successful pulp anesthesia was considered to have occurred when no response was obtained to the maximum stimulation (80 reading) of the pulp tester, at which time treatment commenced. Treatment was regarded as being successfully completed when it was associated with no pain. Data were analyzed by χ(2) and Fisher exact tests. RESULTS: Of the 182 patients, 122 achieved successful pulpal anesthesia within 10 minutes after initial IANB injection; 82 experienced pain-free treatment. ABI and IO allowed more successful (pain-free) treatment (84% and 68%, respectively) than rIANB or PDL supplementary techniques (32% and 48%, respectively); this was statistically significant (P = .001). CONCLUSIONS: IANB injection alone does not always allow pain-free treatment for mandibular teeth with irreversible pulpitis. Supplementary buccal infiltration with 4% articaine with epinephrine and intraosseous injection with 2% lidocaine with epinephrine are more likely to allow pain-free treatment than intraligamentary and repeat IANB injections with 2% lidocaine with epinephrine for patients experiencing irreversible pulpitis in mandibular permanent teeth.

A comparison of the efficacy of 4% articaine with 1:100,000 epinephrine and 2% lidocaine with 1:80,000 epinephrine in achieving pulpal anesthesia in maxillary teeth with irreversible pulpitis.

INTRODUCTION: To assess the efficacy of buccal infiltrations of 4% articaine with 1:100,000 epinephrine and 2% lidocaine with 1:80,000 epinephrine in achieving anesthesia in maxillary teeth with irreversible pulpitis. METHODS: This randomized double-blind clinical trial included 100 patients diagnosed with irreversible pulpitis in maxillary teeth. Patients received 2.0 mL 4% articaine with 1:100,000 epinephrine or 2% lidocaine with 1:80,000 epinephrine in the buccal sulcus adjacent to the tooth with pulpitis. Before and every 2 minutes up to a maximum of 10 minutes after injection, the response of the test tooth was assessed using an electronic pulp tester. Successful pulp anesthesia was considered to have occurred when no response was obtained to the maximum stimulation (80 reading) of the pulp tester during the test period, at which time treatment commenced. Treatment was regarded as being successfully completed when it was associated with no pain. The time to onset of successful pulp anesthesia was recorded for each test tooth. Injection discomfort was recorded on standard 100-mm visual analog scales (VASs). Data were analyzed by the Chi-square and Student t tests. RESULTS: Fifty patients received articaine and 50 received lidocaine. Seventy-three of the 100 patients achieved pulpal anesthesia within 10 minutes of injection: 38 after articaine and 35 after lidocaine (P = .5). The onset of pulpal anesthesia after articaine and lidocaine buccal infiltrations was similar (mean and standard deviations: 4.9 ± 2.7 minutes vs 5.1 ± 2.4 minutes, respectively; t = 0.2; P = .82). Pain-free treatment was completed in 33 patients after articaine and 29 after lidocaine buccal infiltrations (P = .63). Although articaine buccal injection was significantly more comfortable than lidocaine buccal injection (t = 2.3, P = .026), both were associated with mild discomfort on VAS (means ± standard deviation: 10.8 mm ± 11.7 mm vs 17.5 mm ± 17.6 mm, respectively). CONCLUSIONS: There was no significant difference in efficacy between 4% articaine with 1:100,000 epinephrine and 2% lidocaine with 1:80,000 epinephrine in achieving anesthesia in maxillary teeth with irreversible pulpitis after buccal infiltration.

A comparison of the anterior middle superior alveolar nerve block and infraorbital nerve block for anesthesia of maxillary anterior teeth.

BACKGROUND: The authors conducted a study to compare the efficacy of the anterior middle superior alveolar (AMSA) nerve block with that of the infra-orbital nerve block (IONB) in achieving pulpal anesthesia in the anterior maxilla. METHODS: Twenty-eight healthy adult volunteers received 1.0 milliliter of 2 percent lidocaine with 1:80,000 epinephrine as an AMSA nerve block or IONB via computer-controlled local anesthetic delivery (CCLAD) across two visits. The authors used electronic pulp testing to measure pulpal anesthesia. Participants provided subjective reports of lip numbness and injection discomfort. The authors analyzed the data by using the McNemar, Mann-Whitney and t tests. RESULTS: Anesthetic success, defined as two or more consecutive episodes of no sensation in response to maximal stimulation, was significantly greater with the AMSA nerve block than with the IONB in central (P = .012) and lateral (P < .001) incisors; however, anesthesia was achieved in only 42.9 percent of central incisors with the AMSA nerve block. The authors observed a significantly greater number of episodes of no response in the premolar and canine teeth after IONB. Onset of anesthesia was shorter after IONB in canines (P = .002) and central incisors (P = .022). The incidence of subjective lip numbness was 100 percent after IONB and 14.3 percent after AMSA nerve block (P < .001), with numbness lasting twice as long after IONB (P = .019). The authors noted no significant difference in injection discomfort between the two techniques (P = .768). CONCLUSIONS: The IONB produced anesthetic success in canine and premolar teeth, with a more rapid onset than that for the AMSA nerve block. Although the AMSA technique was significantly more successful than IONB in attaining incisor anesthesia, it was ineffective for central incisors, as assessed according to rigorous electronic pulp testing. The IONB and AMSA nerve block produced similar levels of injection discomfort.

Articaine infiltration for anesthesia of mandibular first molars.

A randomized, controlled trial of 31 healthy volunteers compared 4% articaine with 1:100,000 epinephrine buccal infiltration to buccal plus lingual infiltration of the same dose of drug in achieving pulpal anesthesia of mandibular first molar teeth. Data were compared with efficacy of an inferior alveolar nerve block using 2% lidocaine 1:80,000 epinephrine in a cohort of 27 of the volunteers. Anesthesia was determined using electronic pulp testing. Buccal and buccal plus lingual infiltrations of articaine with epinephrine did not differ in efficacy in obtaining pulpal anesthesia for mandibular permanent first molars (p = 0.17). Efficacy of 4% articaine with epinephrine infiltrations for first molar pulp anesthesia was similar to that of an IANB using lidocaine with epinephrine over a 30-minute study period (96 and 80 episodes of no response to maximal stimulation respectively, p = 0.097). Subjective tooth numbness was more common after IANB than buccal infiltration (p = 0.005). The discomfort of buccal infiltration with articaine was volume dependent (p = 0.017) and similar to that of an IANB.

A pilot study of treatment of periodontal-endodontic lesions.

OBJECTIVE: A pilot study to evaluate a standardised treatment protocol for combined periodontal-endodontic lesions (involving staged endodontic and periodontal treatment). PARTICIPANTS: Nine patients with a diagnosis of a combined periodontal-endodontic lesion. METHODS: At baseline, root canal treatment (RCT) was performed by a standard protocol, and simple scaling/oral hygiene instruction provided. After one month, a standardised episode of non-surgical periodontal treatment was undertaken to address residual pocketing. Clinical measurements, including probing depths, attachment levels and bleeding on probing were recorded at baseline, month one and month three. Long-cone periapical radiographs taken using standardised projection geometry at baseline and month three were analysed for bone changes using digital subtraction radiography (DSR). RESULTS: During the study, one patient's affected tooth was extracted. From baseline to month three, there were statistically significant mean probing depth reductions (delta= 0.95mm, 95% CI= 0.20mm, 1.70mm; p= 0.02), mean attachment gains (delta= 1.13mm, 95% CI= 0.29mm, 1.96mm; p= 0.02) and reduction in mean bleeding on probing (delta= 29%, 95% CI= 10%, 49%; p= 0.01). DSR analysis revealed that between month 0 and month three, four teeth demonstrated bone gain, two teeth exhibited bone loss and two teeth showed no change. The mean bone change was in favour of bone gain but failed to achieve statistical significance (p>0.05). CONCLUSIONS: Within the limitations of this pilot study, treatment of periodontal-endodontic lesions by performing RCT prior to periodontal treatment was effective, resulting in improvements in clinical parameters together with alveolar bone gains in a majority of teeth.

Endodontic considerations in the elderly.

Tooth retention has increased significantly in older adults, and dentists are now challenged by the need to preserve critical teeth. There will be a need to consider endodontic therapy, and this paper describes how successful endodontics can be provided for elderly patients. Strategic treatment planning is essential, and preservation of key teeth will facilitate satisfactory oral function for elderly patients. These teeth may be important in achieving and maintaining an intact anterior dental arch, for removable partial denture retention or preservation of alveolar bone. In some cases, this can only be achieved if endodontic procedures are undertaken. When infection of a root canal is present, there is no reason why good quality endodontic therapy should not work in a healthy elderly patient. Elimination of infection can be challenging in narrow root canals, and a systematic approach for improving access into and negotiating these canals is outlined.

Antibiotic prophylaxis for endocarditis, prosthetic joints, and surgery.

It would seem from a review of the evidence that the need for antibiotic prophylaxis in dentistry is overstated. In simple mathematic terms, the risk for providing coverage is greater than the outcomes that could arise if coverage is withheld. In addition, there is the increasing problem of the development of resistant strains and their impact on medicine and dentistry. Yet despite these observations, the profession continues to put their patients at this greater risk. Medico-legal issues do cloud judgments in this area and many dentists err on the side of caution. The profession does require clear, uniform guidelines that are evidence-based. At present, there is still significant debate as to who is at risk from dental-induced bacteremia and what procedures require chemoprophylaxis.