April 27, 2018
Oral premedication and inferior alveolar nerve block in dental literature
In a systematic review and network meta-analysis (NMA) of studies measuring the effect of oral premedication on the anesthetic efficacy of inferior alveolar nerve block (IANB) in patients with irreversible pulpitis (IP), researchers identified dexamethasone, nonsteroidal anti-inflammatory drugs (NSAIDs), or tramadol as most effective. They published their results in the March issue of International Endodontic Journal.
The study’s aim, researchers wrote, was to complete a NMA that compared the relative efficacy of competing oral premedications that are administered to increase success of IANB in patients with IP. “The results of this analysis aim to provide dentists with useful information to make evidence-based decisions on the most effective oral premedication that can effectively increase the success of IANB for treatment of patients with irreversible pulpitis,” they wrote.
The researchers worked from a PICOS (patient or problem; intervention, cause, or prognosis; comparison or control; outcome; and types of studies) framework and addressed the question of which is the most effective oral premedication in increasing the anesthetic success of IANB in patients with irreversible pulpitis undergoing root canal treatment in randomized control trials.
They searched MEDLINE and EBSCOhost databases up to October 2017. Studies included randomized controlled trials comparing a placebo or other premedication with the effect of an oral premedication, either alone or in combination, in the success of IANB for cases of IP.
The researchers measured the quality of the studies using the revised Cochrane risk of bias tool for randomized trials and performed other appraisals of evidence, including NMA, to determine suitability for inclusion. Ultimately, they evaluated 19 studies with a total of 1,654 participants.
Sensitivity analyses proved the superiority of dexamethasone or NSAIDs over any other premedications, researchers found. In order of effectiveness when compared with placebo, as demonstrated by NMA, dexamethasone most ably increased anesthetic success, followed by NSAIDs and then tramadol. The addition of acetaminophen to NSAIDs demonstrated similar efficacy as NSAIDs alone.
“Subgroup analyses of specific dosages in comparison with placebo demonstrated that dexamethasone 0.5 [milligrams] was most effective, followed by ketorolac 10 mg, piroxicam 20 mg, ibuprofen 400 mg + acetaminophen 500 mg and tramadol 50 mg,” researchers wrote.
Researchers determined that more trials are needed to evaluate premedication with dexamethasone or tramadol to improve anesthetic effects of IANB in IP treatment.
Read the original article here.
Consulting Editor: Dr. Susan Wood
Diplomate, American Board of Endodontics
Articaine versus lidocaine in molars with irreversible pulpitis
A study published in the April issue of Journal of Endodontics comparing efficacy of articaine and lidocaine in mandibular molars with irreversible pulpitis (IP) showed that buccal infiltration (BI) with articaine significantly improves success rates for mandibular second molars while articaine and lidocaine performed with similar success in mandibular first molars.
The researchers noted that achieving profound pulpal anesthesia is one of the most difficult situations dentists routinely face when a patient has symptomatic IP in a mandibular molar. The purpose of the researchers’ study was to compare efficacy of 4% articaine with that of 2% lidocaine for supplemental BIs in mandibular first and second molars with IP after a failed inferior alveolar nerve block (IANB).
IANB has a significant failure rate of 10% through 39%, even in patients with healthy, asymptomatic mandibular molars, they noted. The IANB success rate falls to approximately 24% in patients with IP in mandibular molars.
“A relatively easy, safe, and comfortable alternative to conventional IANB is a mandibular BI injection, which, despite the thicker cortical plate, has been shown to be effective for mandibular molar anesthesia in asymptomatic patients,” researchers wrote.
Researchers combined this study’s sample with data from a previous trial.
Designed as a prospective, double-blind, randomized study with volunteer participants who were patients at the University of Michigan School of Dentistry, Ann Arbor, Michigan, the investigation included 199 emergency patients diagnosed with IP of a painful mandibular molar. The participants received an IANB with 4% articaine. Participants with mandibular molars that failed to achieve profound pulpal anesthesia after IANB then received supplemental BI randomly with either 4% articaine or 2% lidocaine.
Endodontic access and instrumentation began 5 minutes after BI. Researchers used the Heft-Parker visual analog scale to assess pain and defined success as less than mild pain during endodontic access and instrumentation.
The results were that IANB with 4% articaine had a success rate of 25%. Articaine and lidocaine achieved similar BI success rates in first molars, but articaine was significantly more successful in second molars. However, BI often did not provide profound pulpal anesthesia and additional techniques may still be required.
Read the original article here.
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Tooth fragment reattachment preferences in dental literature
Simple tooth fragment reattachment is the preferred technique for fractured crowns of anterior teeth, according to the results of a systematic review published online March 7 in Dental Traumatology.
“Fragment reattachment can be considered a valid treatment option in coronal fractures of anterior teeth,” researchers wrote. “The reattachment of a coronal fragment seems to be a practical alternative to placement of conventional composite resin restorations in the management of fractured anterior teeth, since this method is simple, conservative, and provides satisfactory fragment retention and esthetics. It also ensures complete restitution of the tooth’s integrity.”
The researchers based their literature exploration on a PICOS framework: participants (P): fractured teeth; intervention (I): crown fragment reattachment; comparison or control (C): not applicable; outcome measures (O): types of techniques for fractured anterior tooth crowns; types of studies included (S): observational studies.
The researchers used a controlled vocabulary—Medical Subject Heading [MeSH] terms—and free key words in their search strategy and searched bibliographic databases, including PubMed, Latin American and Caribbean Health Sciences Literature, Web of Science, Cochrane Database of Systematic Reviews, and Scopus. They also conducted a partial search of the gray literature using Google Scholar and OpenGrey. They prepared the systematic review according to the Preferred Reporting Items for a Systematic Reviews and Meta-Analyses. To evaluate risk of bias, researchers used a quality assessment tool from the Meta-Analysis of Statistics Assessment and Review Instrument.
Inclusion criteria covered observational studies that were retrieved after searching for the expression “dental trauma” and were aimed at evaluating fractured permanent anterior teeth. Types of studies included, without regard to time or language, were case reports, case series of 3 or more cases, cross-sectional studies, cohort studies, and in vivo clinical trials.
Researchers excluded the following types of articles: reviews, letters, personal opinions, book chapters, conference abstracts, case series with fewer than 3 cases, complex fractures with pulp involvement, fractured posterior tooth crowns, and fractured primary tooth crowns.
The included studies reported predominantly on fragment reattachment with composite resin and resin cement. Researchers noted little consistency among the studies in terms of techniques used for tooth fragment reattachment and length of follow-up. Of 408 articles initially produced from their search, researchers retained 5 for quality analysis.
Researchers concluded that when there is complete fragment adaptation, simple reattachment is preferable to other reattachment techniques that use overcontouring and dentinal groove preparation. They stated that further investigation is needed with larger samples and standard follow-up timeframes.
Read the original article here.
Apical patency and pain in molars with necrotic pulp, apical periodontitis
Maintaining apical patency (AP) does not increase postoperative pain in molars with necrotic pulp and apical periodontitis, according to results of a randomized controlled clinical trial study published in the March issue of Journal of Endodontics.
“Apical patency is a technique in which the apical portion of the canal is maintained free of debris by recapitulation with a small flexible file through the apical foramen,” the researchers wrote. “In this technique, the patency file (e.g., #10 K-file) is set at a length 1 mm longer than the final working length (WL), and the file passively moves through the apical constriction, a width of .05-1 mm, without widening it.”
Researchers noted that maintaining AP has a mixed reputation, with some previous investigators questioning its merits. “Based on the results of previous research, the debates for maintaining or avoiding AP seem equivocal,” they wrote.
Maintenance of AP, researchers found, is taught in just 50% of U.S. dental schools. “In the other half of the dental schools, AP is not taught, claiming that AP might increase the displacement of debris and irritate the periodontal ligament,” researchers wrote.
The researchers designed their study as a prospective, single-center, single-blind, randomized controlled clinical trial. They followed 320 participants with necrotic pulp and apical periodontitis in the maxillary or mandibular molars. The participants, ranging in age from 21 through 45, were selected using a series of random numbers in a 1:1 ratio. They were sorted into 1 of 2 groups—an AP group or a nonapical patency (NAP) group.
The primary outcome was to assess severity of postoperative pain. The secondary outcome was to evaluate analgesic consumption in the 7-day follow-up period. Pain severity was measured using a visual analog scale. Researchers measured statistically significant differences between the study groups by applying the t test (P < .05).
Neither group had participants reporting severe postoperative pain during the follow-up timeframe. However, significant differences emerged in the levels of pain that participants did report. The AP group had visual analog scale scores that were significantly lower in the first 5 days postoperative (P < .05), which fell to nonsignificant afterward. In the NAP group, postoperative pain increased between 12 and 24 hours, while postoperative pain in that period decreased in the AP group, among other substantial pain differences.
No significant difference was found in analgesic consumption (P > .05) between the 2 groups.
Overall, the researchers concluded that the maintenance of AP in molars with necrotic pulp and apical periodontitis was associated with less postoperative pain compared with NAP.
Read the original article here.
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Root Canal Awareness Week resources available
The American Association of Endodontists celebrates the 12th annual Root Canal Awareness Week May 6-12. Root Canal Awareness Week is a nationwide effort to dispel myths about root canal treatment, encourage patients to seek an endodontist for their care, and support the partnership between endodontists and general dentists to provide the highest quality care and save patients’ natural teeth.
Visit aae.org/rcaw for more information, including promotional posters and logos. General dentists also are encouraged to explore the AAE’s clinical resources, including the ENDODONTICS: Colleagues for Excellence newsletters, AAE guidelines and position statements, and treatment planning resources.
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JADA+ Specialty Scans and JADA+ Scans
JADA+ Specialty Scans and JADA+ Scans are quarterly newsletters updating dentists on the latest research in selected specialties and disciplines in dentistry. ADA Publishing and the consulting editors from the represented specialties and disciplines aggregate and summarize research from previously published materials, each item attributed to its publication of origin. JADA+ Scan specialties and disciplines include endodontics, oral pathology, orthodontics, pediatric dentistry, periodontics, prosthodontics, radiology, cosmetic/esthetic and osseointegration. The ADA has engaged the specialty organizations in these areas as well as its own Science Institute and Division of Legal Affairs to assist with these newsletters. View past issues here.
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