Home-based chemically-induced whitening (bleaching) of teeth in adults.

BACKGROUND: With the increased demand for whiter teeth, home-based bleaching products, either dentist-prescribed or over-the-counter products have been exponentially increasing in the past few decades. This is an update of a Cochrane Review first published in 2006. OBJECTIVES: To evaluate the effects of home-based tooth whitening products with chemical bleaching action, dispensed by a dentist or over-the-counter. SEARCH METHODS: Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 12 June 2018), the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 6) in the Cochrane Library (searched 12 June 2018), MEDLINE Ovid (1946 to 12 June 2018), and Embase Ovid (1980 to 12 June 2018). The US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov (12 June 2018) and the World Health Organization International Clinical Trials Registry Platform (12 June 2018) were searched for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. SELECTION CRITERIA: We included in our review randomised controlled trials (RCTs) which involved adults who were 18 years and above, and compared dentist-dispensed or over-the-counter tooth whitening (bleaching) products with placebo or other comparable products.Quasi-randomised trials, combination of in-office and home-based treatments, and home-based products having physical removal of stains were excluded. DATA COLLECTION AND ANALYSIS: Two review authors independently selected trials. Two pairs of review authors independently extracted data and assessed risk of bias. We estimated risk ratios (RRs) for dichotomous data, and mean differences (MDs) or standardised mean difference (SMD) for continuous data, with 95% confidence intervals (CIs). We assessed the certainty of the evidence using the GRADE approach. MAIN RESULTS: We included 71 trials in the review with 26 studies (1398 participants) comparing a bleaching agent to placebo and 51 studies (2382 participants) comparing a bleaching agent to another bleaching agent. Two studies were at low overall risk of bias; two at high overall risk of bias; and the remaining 67 at unclear overall risk of bias.The bleaching agents (carbamide peroxide (CP) gel in tray, hydrogen peroxide (HP) gel in tray, HP strips, CP paint-on gel, HP paint-on gel, sodium hexametaphosphate (SHMP) chewing gum, sodium tripolyphosphate (STPP) chewing gum, and HP mouthwash) at different concentrations with varying application times whitened teeth compared to placebo over a short time period (from 2 weeks to 6 months), however the certainty of the evidence is low to very low.In trials comparing one bleaching agent to another, concentrations, application method and application times, and duration of use varied widely. Most of the comparisons were reported in single trials with small sample sizes and event rates and certainty of the evidence was assessed as low to very low. Therefore the evidence currently available is insufficient to draw reliable conclusions regarding the superiority of home-based bleaching compositions or any particular method of application or concentration or application time or duration of use.Tooth sensitivity and oral irritation were the most common side effects which were more prevalent with higher concentrations of active agents though the effects were mild and transient. Tooth whitening did not have any effect on oral health-related quality of life. AUTHORS' CONCLUSIONS: We found low to very low-certainty evidence over short time periods to support the effectiveness of home-based chemically-induced bleaching methods compared to placebo for all the outcomes tested.We were unable to draw any conclusions regarding the superiority of home-based bleaching compositions or any particular method of application or concentration or application time or duration of use, as the overall evidence generated was of very low certainty. Well-planned RCTs need to be conducted by standardising methods of application, concentrations, application times, and duration of treatment.

Does Maintaining Apical Patency during Instrumentation Increase Postoperative Pain or Flare-up Rate after Nonsurgical Root Canal Treatment? A Systematic Review of Randomized Controlled Trials.

INTRODUCTION: The concept of maintaining apical patency (AP) is a controversial issue in endodontics. The primary objectives of this systematic review of randomized controlled trials (RCTs) were to determine the influence of maintaining AP during instrumentation on postoperative pain severity and the prevalence of flare-ups. A second objective was to assess the effect of maintaining AP on the use of analgesics. METHODS: RCTs and controlled clinical trials were searched for in MEDLINE (Ovid), Embase (Ovid), and the Cochrane Library. Four reviewers independently screened all identified articles for eligibility. The included studies were assessed for bias using the Cochrane Risk of Bias Tool. The Grading of Recommendations Assessment, Development and Evaluation approach was used to rate the quality of the body of evidence. Because of the considerable heterogeneity of the studies, a meta-analysis was not possible. Therefore, the results were analyzed narratively. RESULTS: Five RCTs that included a total of 848 patients were found eligible and included in the review. An assessment of the risk of bias in the included studies provided results that classified the studies as showing a low risk (n = 1), high risk (n = 1), or unclear risk (n = 3) of bias. The available evidence indicated that maintaining AP (1) did not increase postoperative pain in teeth with nonvital pulp, (2) did not increase postoperative pain in teeth with vital pulp, and (3) did not cause (0%) flare-ups. The available evidence also indicated that maintaining AP did not increase analgesic use. The available evidence indicated that maintaining AP did not increase postoperative pain when a single-visit or 2-visit root canal treatment approach was used. CONCLUSIONS: In light of the current evidence, maintaining AP does not increase postoperative pain in teeth with vital/nonvital pulp when compared with nonapical patency (low to moderate quality evidence). Furthermore, maintaining AP did not cause flare-ups (low evidence) and did not increase analgesic use (moderate evidence).

Maintaining Apical Patency Does Not Increase Postoperative Pain in Molars with Necrotic Pulp and Apical Periodontitis: A Randomized Controlled Trial.

INTRODUCTION: This prospective, single-center, single-blind, randomized controlled trial aimed to evaluate whether maintaining apical patency (AP) during endodontic treatment increases postoperative pain in molar teeth with necrotic pulp and apical periodontitis. METHODS: Three hundred twenty qualified patients between 21 and 45 years of age were randomized into 1 of 2 groups (the AP group and the nonapical patency [NAP] group) using a series of random numbers in a 1:1 ratio. Qualified patients were selected from patients who had necrotic pulp and apical periodontitis in the maxillary or mandibular molar teeth. The primary outcome was to assess postoperative pain severity, and the secondary outcome was to evaluate analgesic consumption during the 7-day follow-up period using the visual analog scale (VAS). The VAS consisted of a 100-mm line. Pain severity was evaluated as no pain (0-4 mm), mild pain (5-44 mm), moderate pain (45-74 mm), and severe pain (75-100 mm). The Student t test was used to identify statistically significant differences between the study groups (P < .05). RESULTS: The mean VAS scores were significantly lower in the AP group in the first 5 postoperative days (P < .05); after which, it was nonsignificant. In the NAP group, the postoperative pain increased between 12 and 24 hours, whereas the postoperative pain decreased in the AP group during that period. At 12 and 24 hours, the mean VAS scores for the AP group were 42.90 and 37.78 mm, respectively. The mean VAS scores for the NAP group were 64.46 and 65.74 mm, respectively. None of the patients had severe postoperative pain during the follow-up period. No significant difference was found in analgesic consumption (P > .05) between the groups. CONCLUSIONS: The maintenance of AP in molar teeth with necrotic pulp and apical periodontitis was associated with less postoperative pain when compared with NAP.

The Effect of Foraminal Enlargement of Necrotic Teeth with a Continuous Rotary System on Postoperative Pain: A Randomized Controlled Trial.

INTRODUCTION: This single-blind, randomized controlled trial aimed to evaluate whether foraminal enlargement (FE) with a continuous rotary system during endodontic treatment causes more postoperative pain than nonforaminal enlargement (NFE). METHODS: Seventy qualified patients were randomized into 1 of 2 groups in a 1:1 ratio using a series of random numbers: the FE group and the NFE group. The patients were followed up for 7 days to evaluate between-group differences in the outcome measures. The study participants were selected from among patients who had necrosis and apical periodontitis in the maxillary or mandibular molar teeth. The primary outcome was to assess postoperative pain severity, and the secondary outcome was to evaluate analgesic consumption during the follow-up period. Pain severity was evaluated for the first 7 days using a visual analog scale (VAS). The VAS consisted of a 100-mm line. Pain severity was assessed as no pain (0-4 mm), mild pain (5-44 mm), moderate pain (45-74 mm), and severe pain (75-100 mm). The quality of life of patients during the follow-up period was assessed using a quality of life scale. The Student t test was used to identify statistically significant differences between the study groups (P < .05). RESULTS: A significant difference was noted in postoperative pain in the first 2 days; the FE group experienced more pain than the conventional NFE group (P < .05). In the FE group, 12 and 11 patients (34% and 31%) had severe postoperative pain (VAS score, >74 mm) on the first day and second day, respectively. VAS pain scores between the groups were not different (P > .05) on other days. No significant difference was found in analgesic consumption between the groups (P > .05). CONCLUSIONS: On the basis of the VAS results, this randomized controlled trial indicates that FE causes more pain on the first 2 days after an endodontic treatment.

Critical Assessment of Search Strategies in Systematic Reviews in Endodontics.

INTRODUCTION: The aim of this study was to perform an overview of literature search strategies in systematic reviews (SRs) published in 2 endodontic journals, Journal of Endodontics and International Endodontic Journal. METHODS: A search was done by using the MEDLINE (PubMed interface) database to retrieve the articles published between January 1, 2000 and December 31, 2015. The last search was on January 10, 2016. All the SRs published in the 2 journals were retrieved and screened. Eligible SRs were assessed by using 11 questions about search strategies in the SRs that were adapted from 2 guidelines (ie, AMSTAR checklist and the Cochrane Handbook). RESULTS: A total of 83 SRs were retrieved by electronic search. Of these, 55 were from the Journal of Endodontics, and 28 were from the International Endodontic Journal. After screening, 2 SRs were excluded, and 81 SRs were included in the study. Some issues, such as search of grey literature and contact with study authors, were not fully reported (30% and 25%, respectively). On the other hand, some issues, such as the use of index terms and key words and search in at least 2 databases, were reported in most of the SRs (97% and 95%, respectively). The overall quality of the search strategy in both journals was 61%. No significant difference was found between the 2 journals in terms of evaluation criteria (P > .05). CONCLUSIONS: There exist areas for improving the quality of reporting of search strategies in SRs; for example, grey literature should be searched for unpublished studies, no language limitation should be applied to databases, and authors should make an attempt to contact the authors of included studies to obtain further relevant information.

Ultrasonically Activated Irrigation to Remove Calcium Hydroxide from Apical Third of Human Root Canal System: A Systematic Review of In Vitro Studies.

INTRODUCTION: The aim of this systematic review was to summarize the outcomes of in vitro studies comparing ultrasonically activated irrigation versus other irrigation techniques for removing calcium hydroxide (Ca[OH]2) from the apical third of root canals. METHODS: The research question was developed according to the PICO strategy. A comprehensive literature search was performed. The Medline, Embase, and TRIP electronic databases were searched. A hand search of the reference lists of identified articles was performed to isolate relevant articles. Two reviewers critically assessed the studies against our inclusion and exclusion criteria. Evaluation of the risk of bias of the studies was performed independently by the 2 reviewers. RESULTS: After study selection, 62 were assessed for eligibility. Of these, 9 met the inclusion criteria and were included in the systematic review. Because considerable heterogeneity was found in the methodologies, it was not possible to combine the results of studies in a meta-analysis. Ultrasonically activated irrigation was found to be superior to syringe irrigation and apical negative pressure irrigation, but insufficient evidence was found to indicate its superiority over the other irrigation techniques such as sonically activated irrigation, the Self-Adjusting File, (ReDent-Nova, Ra'anana, Israel) and the RinsEndo, (Dürr Dental, Bietigheim, Germany). CONCLUSIONS: On the basis of available evidence, we determined the effectiveness of ultrasonically activated irrigation compared with syringe and apical negative pressure irrigation. Because of the small sample sizes, low number of included studies, and limitations, further research is needed to confirm our results.