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European Journal of Paediatric Dentistry Dec 2021The aim of this systematic review was to evaluate the clinical outcome of partial pulpotomy, pulpotomy and pulpectomy for treating primary teeth with normal or infected...
AIM
The aim of this systematic review was to evaluate the clinical outcome of partial pulpotomy, pulpotomy and pulpectomy for treating primary teeth with normal or infected pulp or with irreversible pulpitis.
METHODS
Two reviewers on Pubmed and ISI Web of Science performed a comprehensive literature review of publications from 1966 until July 2019. Pico outline was used to facilitate literature research. Among abstracts, publications were selected according to the following criteria: prospective clinical study, correct indication for the performed treatment, clear definition of clinical and/or radiographic success criteria and at least 6-month follow-up period. The strict selection criteria under the keywords "pulpotomy", "partial pulpotomy" and "pulpectomy" resulted in a limited amount of randomised controlled trials (RCT) or controlled clinical trials (CT). Qualitative assessment of the selected clinical studies and level of evidence was included according to the criteria described by the Oxford Centre for Evidence-Based Medicine (CEBM).
CONCLUSION
Prerequisites for a successful pulpotomy are symptom-free teeth, sterile removal of coronal pulp and haemostasis. Both MTA and formocresol perform well for partial pulpotomies after caries exposure. Formocresol had been the most popular amputation material for pulpotomies. Due to the potential side effects, other medicaments, such as ferric sulfate, mineral trioxide aggregate (MTA) or NaOCl are suggested. Grey and white MTA yeld the same results. Lasers are not recommended due to their large diversity. Regarding pulpectomy, the conditions, procedures, and evaluation for the treatment were not well defined in the studies. Nevertheless, there is evidence to use calcium hydroxide, zinc oxide eugenol paste or iodoform based pastes as root filling materials for non-vital molars. Pulpectomies showed better success rates than pulpotomies. Stainless steel crowns are recommended as definite restorations after both endodontic treatments. Longer follow-up periods, further clinical studies with comparable conditions and clear definition of evaluation criteria are needed to further confirm the results of endodontic treatment in primary teeth.
Topics: Calcium Compounds; Drug Combinations; Humans; Molar; Oxides; Pulpectomy; Pulpotomy; Silicates; Tooth, Deciduous; Treatment Outcome; Zinc Oxide-Eugenol Cement
PubMed: 35034465
DOI: 10.23804/ejpd.2021.22.04.4 -
Journal of Endodontics Sep 2020A sound and vital pulp is an essential prerequisite for long-term tooth survival and preservation. However, current endodontic treatment concepts are based on the... (Review)
Review
INTRODUCTION
A sound and vital pulp is an essential prerequisite for long-term tooth survival and preservation. However, current endodontic treatment concepts are based on the removal of inflamed or necrotic pulp tissue and the replacement by a synthetic biomaterial. Recently, total or partial pulp regeneration has been proposed as an alternative treatment concept. The aim of this review was to evaluate the current options of pulp treatment and regenerative approaches, both for immature and mature teeth, in a clinical context.
METHODS
Clinical success rates of classic treatment options such as pulpotomy or root canal filling after pulpectomy or the removal of necrotic tissue are compared with recent reports on regenerative approaches like revitalization or partial and total pulp regeneration.
RESULTS
Revitalization in immature teeth with pulp necrosis is an additional treatment option besides placing an apical plug, leading to clinically acceptable outcomes, although with low predictability regarding the completion of root formation. Coronal regeneration of the amputated pulp in immature teeth constitutes a promising scientific approach, but data from clinical studies are missing. Mature teeth display a reduced potential for regeneration. Regenerative procedures using cell transplantation or cell homing are mainly in the experimental phase with only 2 clinical studies on cell transplantation. In parallel to the further development of regenerative therapies, the classification of pulp diseases should be revised, and the diagnostic tools need improvement.
CONCLUSIONS
The rethinking of current concepts for biology-based treatments and improved diagnostic concepts might postpone the point of root canal filling depending on the clinical situation.
Topics: Dental Pulp; Dental Pulp Necrosis; Humans; Pulpotomy; Regeneration; Root Canal Therapy
PubMed: 32950188
DOI: 10.1016/j.joen.2020.06.037 -
The Cochrane Database of Systematic... May 2018In children, dental caries (tooth decay) is among the most prevalent chronic diseases worldwide. Pulp interventions are indicated for extensive tooth decay. Depending on... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
In children, dental caries (tooth decay) is among the most prevalent chronic diseases worldwide. Pulp interventions are indicated for extensive tooth decay. Depending on the severity of the disease, three pulp treatment techniques are available: direct pulp capping, pulpotomy and pulpectomy. After treatment, the cavity is filled with a medicament. Materials commonly used include mineral trioxide aggregate (MTA), calcium hydroxide, formocresol or ferric sulphate.This is an update of a Cochrane Review published in 2014 when insufficient evidence was found to clearly identify one superior pulpotomy medicament and technique.
OBJECTIVES
To assess the effects of different pulp treatment techniques and associated medicaments for the treatment of extensive decay in primary teeth.
SEARCH METHODS
Cochrane Oral Health's Information Specialist searched the Cochrane Oral Health Group's Trials Register (to 10 August 2017), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2017, Issue 7), MEDLINE Ovid (1946 to 10 August 2017), Embase Ovid (1980 to 10 August 2017) and the Web of Science (1945 to 10 August 2017). OpenGrey was searched for grey literature. The US National Institutes of Health Trials Registry (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform 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 randomised controlled trials (RCTs) comparing interventions that combined a pulp treatment technique with a medicament or device in children with extensive decay in the dental pulp of their primary teeth.
DATA COLLECTION AND ANALYSIS
Two review authors independently extracted data and assessed 'Risk of bias'. We contacted authors of RCTs for additional information when necessary. The primary outcomes were clinical failure and radiological failure, as defined in trials, at six, 12 and 24 months. We performed data synthesis with pair-wise meta-analyses using fixed-effect models. We assessed statistical heterogeneity by using I² coefficients.
MAIN RESULTS
We included 40 new trials bringing the total to 87 included trials (7140 randomised teeth) for this update. All were small, single-centre trials (median number of randomised teeth = 68). All trials were assessed at unclear or high risk of bias.The 87 trials examined 125 different comparisons: 75 comparisons of different medicaments or techniques for pulpotomy; 25 comparisons of different medicaments for pulpectomy; four comparisons of pulpotomy and pulpectomy; and 21 comparisons of different medicaments for direct pulp capping.The proportion of clinical failures and radiological failures was low in all trials. In many trials, there were either no clinical failures or no radiographic failures in either study arm.For pulpotomy, we assessed three comparisons as providing moderate-quality evidence. Compared with formocresol, MTA reduced both clinical and radiological failures, with a statistically significant difference at 12 months for clinical failure and at six, 12 and 24 months for radiological failure (12 trials, 740 participants). Compared with calcium hydroxide, MTA reduced both clinical and radiological failures, with statistically significant differences for clinical failure at 12 and 24 months. MTA also appeared to reduce radiological failure at six, 12 and 24 months (four trials, 150 participants) (low-quality evidence). When comparing calcium hydroxide with formocresol, there was a statistically significant difference in favour of formocresol for clinical failure at six and 12 months and radiological failure at six, 12 and 24 months (six trials (one with no failures), 332 participants).Regarding pulpectomy, we found moderate-quality evidence for two comparisons. The comparison between Metapex and zinc oxide and eugenol (ZOE) paste was inconclusive, with no clear evidence of a difference between the interventions for failure at 6 or 12 months (two trials, 62 participants). Similarly inconclusive, there was no clear evidence of a difference in failure between Endoflas and ZOE (outcomes measured at 6 months; two trials, 80 participants). There was low-quality evidence of a difference in failure at 12 months that suggested ZOE paste may be better than Vitapex (calcium hydroxide/iodoform) paste (two trials, 161 participants).Regarding direct pulp capping, the small number of studies undertaking the same comparison limits any interpretation. We assessed the quality of the evidence as low or very low for all comparisons. One trial appeared to favour formocresol over calcium hydroxide; however, there are safety concerns about formocresol.
AUTHORS' CONCLUSIONS
Pulp treatment for extensive decay in primary teeth is generally successful. Many included trials had no clinical or radiological failures in either trial arm, and the overall proportion of failures was low. Any future trials in this area would require a very large sample size and follow up of a minimum of one year.The evidence suggests MTA may be the most efficacious medicament to heal the root pulp after pulpotomy of a deciduous tooth. As MTA is relatively expensive, future research could be undertaken to confirm if Biodentine, enamel matrix derivative, laser treatment or Ankaferd Blood Stopper are acceptable second choices, and whether, where none of these treatments can be used, application of sodium hypochlorite is the safest option. Formocresol, though effective, has known concerns about toxicity.Regarding pulpectomy, there is no conclusive evidence that one medicament or technique is superior to another, and so the choice of medicament remains at the clinician's discretion. Research could be undertaken to confirm if ZOE paste is more effective than Vitapex and to evaluate other alternatives.Regarding direct pulp capping, the small number of studies and low quality of the evidence limited interpretation. Formocresol may be more successful than calcium hydroxide; however, given its toxicity, any future research should focus on alternatives.
Topics: Aluminum Compounds; Calcium Compounds; Calcium Hydroxide; Child; Child, Preschool; Controlled Clinical Trials as Topic; Dental Caries; Dental Cements; Dental Materials; Drug Combinations; Electric Stimulation Therapy; Ferric Compounds; Formocresols; Humans; Molar; Oxides; Pulpectomy; Pulpotomy; Randomized Controlled Trials as Topic; Silicates; Tooth, Deciduous; Treatment Failure; Zinc Oxide-Eugenol Cement
PubMed: 29852056
DOI: 10.1002/14651858.CD003220.pub3 -
International Endodontic Journal Apr 2021The outcome of vital pulp treatment after carious pulp exposure is multifactorial and related to the procedure, biomaterial and pre-operative pulpal diagnosis. (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
The outcome of vital pulp treatment after carious pulp exposure is multifactorial and related to the procedure, biomaterial and pre-operative pulpal diagnosis.
OBJECTIVES
To conduct a systematic review and meta-analysis determining the outcome of direct pulp capping (DPC) in mature permanent teeth with a cariously exposed pulp and a clinical diagnosis of reversible pulpitis, and ascertain whether the capping material influences the outcome.
METHODS
Sources: MEDLINE Ovid-SP, Cochrane Central Register of Controlled Trials (CENTRAL), International Clinical Trials Registry Platform (ICTRP), ClinicalTrials.gov, Embase and Web of Science until April 2020. Inclusion: Prospective, retrospective cohort studies and randomized trials investigating DPC outcome or comparing different capping materials after carious pulp exposure. Exclusion: Primary teeth, mechanical, traumatic or not specified pulp exposure, teeth with irreversible pulpitis or no pulpal diagnosis. Risk of bias assessed using Cochrane and modified Downs and Black quality assessment checklist. Meta-analysis on combined clinical/radiographic outcome was performed using a random effect model. Success was defined as absence of signs and symptoms of irreversible pulpitis, apical periodontitis or loss of pulp vitality.
RESULTS
Quality assessment highlighted four non-randomized studies to be of fair and five of poor quality. Four randomized trials had a high risk of bias. The pooled success rate differed based on material and follow-up. Calcium hydroxide success rate was 74% at 6-months, 65% at 1-year, 59% at 2-3 years and 56% at 4-5 years. Mineral trioxide aggregate (MTA) success was 91%, 86%, 84% and 81% at the same time points. Biodentine success was 96% at 6-months, 86% at 1 year and 86% at 2-3 years. The meta-analysis revealed MTA had better success than calcium hydroxide at 1-year (OR 2.66, 95% CI; 1.46- 4.84, P = 0.001) and 2- to 3-year follow-up (OR 2.21, 95% CI; 1.42-3.44, P = 0.0004). There was no difference between MTA and Biodentine.
DISCUSSION
These results were based on poor methodological quality studies. The effect size for of MTA vs Ca(OH)2, although modest, was consistent with narrow CI.
CONCLUSIONS
Low-quality evidence suggests a high success rate for direct pulp capping in teeth with cariously exposed pulps with better long-term outcomes for MTA and Biodentine compared with calcium hydroxide.
Topics: Aluminum Compounds; Calcium Compounds; Dental Caries; Dental Pulp Capping; Dentition, Permanent; Drug Combinations; Humans; Oxides; Prospective Studies; Pulp Capping and Pulpectomy Agents; Retrospective Studies; Silicates; Treatment Outcome
PubMed: 33222178
DOI: 10.1111/iej.13449 -
Clinical and Experimental Dental... Jun 2019Zinc oxide eugenol (ZOE) has traditionally been used as a root filling material in primary teeth pulpectomy. Calcium hydroxide and iodoform (Ca(OH)/iodoform) may have... (Comparative Study)
Comparative Study Meta-Analysis
Zinc oxide eugenol (ZOE) has traditionally been used as a root filling material in primary teeth pulpectomy. Calcium hydroxide and iodoform (Ca(OH)/iodoform) may have advantages as a root canal filling material to evaluate treatment success of Ca(OH)/iodoform pulpectomy in primary teeth compared with ZOE based on clinical and radiographical criteria. All human clinical studies reporting clinical and radiographical outcomes of Ca(OH)iodoform compared with ZOE in primary teeth pulpectomy were identified in digital bibliographic databases. Two authors independently selected studies and extracted relevant study characteristics. Success of treatment was based on an accomplishment of specific clinical and radiographical criteria. Meta-analyses were performed to appraise study heterogeneity and aggregated statistics. Out of 5,000 articles identified in initial search, 15 articles met all inclusion criteria, while 10 were included in the meta-analyses. At 6- and 12-month follow-up, there were no statistically significant differences in the clinical and radiographical success rates of Ca(OH)/iodoform and ZOE. However, ZOE was shown to have statistically significant higher success rates at ≥18-month follow-up. On the basis of the findings of this systematic review, we recommend that Ca(OH)/iodoform be utilized for pulpectomy in primary teeth nearing exfoliation; conversely, ZOE should be utilized when exfoliation is not expected to occur soon. Future randomized control clinical trials with a long-term follow-up are needed before a reliable conclusion can be drawn as to the best pulpectomy material. The success of pulpectomy in primary teeth depends on selecting the ideal root canal filling material. It is challenging to select the appropriate filling materials for primary teeth. ZOE or ZOE/iodoform combined with Ca(OH) appears to be the materials of choice if primary teeth are not nearing exfoliation. More high-quality randomized control clinical trials with a long-term follow-up period are needed before a reliable conclusion can be drawn as to the best pulpectomy material in primary teeth (systematic review registration number: CRD42016037563).
Topics: Calcium Hydroxide; Humans; Pulpectomy; Root Canal Filling Materials; Silicones; Tooth, Deciduous; Zinc Oxide-Eugenol Cement
PubMed: 31249711
DOI: 10.1002/cre2.173 -
Journal of Endodontics Oct 2023Dens evaginatus (DE) is a dental anomaly with a supernumerary tubercle projection that typically contains dentin and pulp tissue. However, the tubercle projection can... (Review)
Review
INTRODUCTION
Dens evaginatus (DE) is a dental anomaly with a supernumerary tubercle projection that typically contains dentin and pulp tissue. However, the tubercle projection can fracture, exposing the dentin and potentially the dental pulp, which induces pulpal diseases. Managing DE should be primarily based on the clinical diagnosis of the pulp.
METHODS
The literature search in prevalence, prophylaxis, and management of dens evaginatus was performed in PubMed database as well as by manual search, in which the related contents were collected and descriptively analyzed.
RESULTS
Of the 264 searched literatures, 62 articles were included for this scoping review. The prophylactic management of the tubercle of DE teeth with a normal pulp should be performed as early as possible by the prep-and-fill technique or the reinforcement technique to preserve tooth vitality and continued root development, with the former reported to be superior compared with the latter. Furthermore, DE teeth with reversible pulpitis should be managed with the prep-and-fill technique. For DE teeth with irreversible pulpitis, vital pulp therapy, ie, partial or full/coronal pulpotomy, should be considered when the pulpal inflammation is limited to the coronal pulp to preserve the vitality of the radicular pulp that induces apexogenesis. A pulpectomy should be performed if the pulpal inflammation has progressed into the radicular pulp. For DE teeth with pulpal necrosis (or after pulpectomy) and immature roots, mineral trioxide aggregate apexification or regenerative endodontic procedures are the treatment options. For DE teeth with pulpal necrosis and complete root formation, nonsurgical root canal treatment is the treatment of choice. A flow chart of the decision-making for managing DE teeth based on pulpal diagnosis is proposed.
CONCLUSION
DE teeth should be properly managed, by prophylaxis or treatment, depending on pulpal diagnosis and related factors.
Topics: Humans; Pulpitis; Bicuspid; Root Canal Therapy; Dental Pulp Necrosis; Inflammation
PubMed: 37506764
DOI: 10.1016/j.joen.2023.07.017 -
Journal of Endodontics Jan 2023This retrospective study evaluated the long-term outcome of direct pulp capping in mature teeth using specific case selection and treatment procedures.
INTRODUCTION
This retrospective study evaluated the long-term outcome of direct pulp capping in mature teeth using specific case selection and treatment procedures.
METHODS
Teeth with pulp exposure due to advanced caries and clinical diagnosis of reversible pulpitis were treated by direct pulp capping. Treatments were conducted over a period of 15 years by a single operator. Under magnification, caries was completely removed, the exposed pulp examined, and capped with either pure calcium hydroxide or a calcium hydroxide-based cement. The cavity was restored and the long-term outcome evaluated from 1 to >35 years. Teeth that were asymptomatic, responded to sensibility pulp tests within normal limits, and showed no radiographic periapical changes were categorized as success. Teeth with no response to pulp tests and/or showing radiographic evidence of apical periodontitis were classified as failures. The effects of independent variables (sex, age, symptoms, number and size of pulp exposures, bleeding time, capping material, bases used over the capping material, and final coronal restoration) on the outcome were evaluated.
RESULTS
In general, 225 teeth from 148 patients were available for follow-up examination in at least one of the evaluated periods. The success rate of the direct pulp capping procedure was 100%, 95%, 95%, 86%, and 89% at 1-, 5-, 10-, 20-, and 35-year follow-up examination, respectively. The main variable significantly affecting the treatment outcome in all follow-up periods was the quality/presence of coronal restoration (P < .001). Other isolated variables associated with the outcome included the size and number of pulp exposures at the 20-year follow-up, and the exposure size, capping material, and restoration type at the 35-year follow-up. Multiple regression analysis confirmed the results for exposure size (P < .05), and disclosed a higher proportion of failures at 5 years when varnish was used as the base.
CONCLUSIONS
A very high success rate of the direct pulp capping with calcium hydroxide was observed, especially in the first 10 years following treatment. The main variable influencing the outcome was the quality of the coronal restoration.
Topics: Humans; Calcium Hydroxide; Dental Pulp Capping; Pulp Capping and Pulpectomy Agents; Retrospective Studies; Calcium Compounds; Aluminum Compounds; Silicates; Oxides; Dental Caries; Dental Cements; Treatment Outcome
PubMed: 36375647
DOI: 10.1016/j.joen.2022.11.005 -
Pediatric Dentistry Jul 2020The purpose of this systematic review and meta-analysis was to assess success rates for nonvital treatment in primary teeth for caries/trauma. Databases were searched... (Meta-Analysis)
Meta-Analysis
The purpose of this systematic review and meta-analysis was to assess success rates for nonvital treatment in primary teeth for caries/trauma. Databases were searched between 1960 and 2020 for randomized controlled trials, cohorts, case series, and in vitro studies. The primary outcome was overall success (clinical and radiographic) for pulpectomy and lesion sterilization tissue repair (LSTR). Included articles were independently determined, agreed upon, data extraction assessed, risk of bias, meta-analyses, and assignment of quality of evidence (GRADE). Comparing teeth with and without root resorption, pulpectomy success was better (P<0.001) in teeth without preoperative root resorption. Success with pulpectomies performed with zinc oxide eugenol [ZOE] and with Endoflas (ZOE plus iodoform plus calcium hydroxide) did not differ from that observed using Vitapex or Metapex (iodoform plus calcium hydroxide; P0.50) after 18 months; however, Endoflas and ZOE success rates remained near 90 percent versus 71 percent or less for iodoform. Network analysis ratings showed Endoflas and ZOE performed better than iodoform alone. Also, LSTR performed better (P<0.001) than pulpectomies in teeth with preoperative root resorption, but pulpectomy results were superior (P=0.09) if roots were intact. Rotary instrumentation of root canals was significantly faster (P<0.001) than manual instrumentation. Success rates were not impacted by method of obturation or root length determination, type of tooth, number of visits, irrigants, smear layer removal, or timing/type of final restoration. Eighteen-month success rates support Endloflas and zinc oxide eugenol pulpectomies over iodoform pulpectomies. Lesion sterilization tissue repair had limited indication for teeth with resorbed roots.
Topics: Calcium Hydroxide; Dental Caries; Humans; Pulpectomy; Root Canal Filling Materials; Root Resorption; Tooth, Deciduous; Zinc Oxide-Eugenol Cement
PubMed: 32847665
DOI: No ID Found -
European Archives of Paediatric... Feb 2018Biodentine™ has frequently been acknowledged in the literature as a promising material and serves as an important representative of tricalcium silicate based cements... (Review)
Review
INTRODUCTION
Biodentine™ has frequently been acknowledged in the literature as a promising material and serves as an important representative of tricalcium silicate based cements used in dentistry.
AIM
To provide an update on the physical and biological properties of Biodentine™ and to compare these properties with those of other tricalcium silicate cements namely, different variants of mineral trioxide aggregate (MTA) such as ProRoot MTA, MTA Angelus, Micro Mega MTA (MM-MTA), Retro MTA, Ortho MTA, MTA Plus, GCMTA, MTA HP and calcium enriched mixture (CEM), Endosequence and Bioaggregate™.
STUDY DESIGN
A comprehensive literature search for publications from November 20, 2013 to November 20, 2016 was performed by two independent reviewers on Medline (PubMed), Embase, Web of Science, CENTRAL (Cochrane), SIGLE, SciELO, Scopus, Lilacs and clinicaltrials.gov. Electronic and hand search was carried out to identify randomised control trials (RCTs), case control studies, case series, case reports, as well as in vitro and animal studies published in the English language.
CONCLUSIONS
The enhanced physical and biologic properties of Biodentine™ could be attributed to the presence of finer particle size, use of zirconium oxide as radiopacifier, purity of tricalcium silicate, absence of dicalcium silicate, and the addition of calcium chloride and hydrosoluble polymer. Furthermore, as Biodentine™ overcomes the major drawbacks of MTA it has great potential to revolutionise the different treatment modalities in paediatric dentistry and endodontics especially after traumatic injuries. Nevertheless, high quality long-term clinical studies are required to facilitate definitive conclusions.
Topics: Aluminum Compounds; Animals; Calcium Compounds; Dental Cements; Drug Combinations; Humans; Oxides; Particle Size; Pulp Capping and Pulpectomy Agents; Silicates
PubMed: 29372451
DOI: 10.1007/s40368-018-0328-x -
The Cochrane Database of Systematic... Sep 2018Dental pain can have a detrimental effect on quality of life. Symptomatic apical periodontitis and acute apical abscess are common causes of dental pain and arise from... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Dental pain can have a detrimental effect on quality of life. Symptomatic apical periodontitis and acute apical abscess are common causes of dental pain and arise from an inflamed or necrotic dental pulp, or infection of the pulpless root canal system. Clinical guidelines recommend that the first-line treatment for teeth with these conditions should be removal of the source of inflammation or infection by local, operative measures, and that systemic antibiotics are currently only recommended for situations where there is evidence of spreading infection (cellulitis, lymph node involvement, diffuse swelling) or systemic involvement (fever, malaise). Despite this, there is evidence that dentists frequently prescribe antibiotics in the absence of these signs. There is concern that this could contribute to the development of antibiotic-resistant bacterial colonies within both the individual and the community. This review is an update of the original version that was published in 2014.
OBJECTIVES
To evaluate the effects of systemic antibiotics provided with or without surgical intervention (such as extraction, incision and drainage of a swelling, or endodontic treatment), with or without analgesics, for symptomatic apical periodontitis and acute apical abscess in adults.
SEARCH METHODS
Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 26 February 2018), the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 1) in the Cochrane Library (searched 26 February 2018), MEDLINE Ovid (1946 to 26 February 2018), Embase Ovid (1980 to 26 February 2018), and CINAHL EBSCO (1937 to 26 February 2018). The US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. A grey literature search was conducted using OpenGrey (to 26 February 2018) and ZETOC Conference Proceedings (1993 to 26 February 2018). No restrictions were placed on the language or date of publication when searching the electronic databases.
SELECTION CRITERIA
Randomised controlled trials of systemic antibiotics in adults with a clinical diagnosis of symptomatic apical periodontitis or acute apical abscess, with or without surgical intervention (considered in this situation to be extraction, incision and drainage or endodontic treatment) and with or without analgesics.
DATA COLLECTION AND ANALYSIS
Two authors screened the results of the searches against inclusion criteria, extracted data and assessed risk of bias independently and in duplicate. We calculated mean differences (MD) (standardised mean difference (SMD) when different scales were reported) and 95% confidence intervals (CI) for continuous data. A fixed-effect model was used in the meta-analysis as there were fewer than four studies. We contacted study authors to obtain missing information.
MAIN RESULTS
We included two trials in this review, with 62 participants included in the analyses. Both trials were conducted in university dental schools in the USA and compared the effects of oral penicillin V potassium (penicillin VK) versus a matched placebo when provided in conjunction with a surgical intervention (total or partial pulpectomy) and analgesics to adults with acute apical abscess or symptomatic necrotic tooth. The patients included in these trials had no signs of spreading infection or systemic involvement (fever, malaise). We assessed one study as having a high risk of bias and the other study as having unclear risk of bias.The primary outcome variables reported in both studies were participant-reported pain and swelling (one trial also reported participant-reported percussion pain). One study reported the type and number of analgesics taken by participants. One study recorded the incidence of postoperative endodontic flare-ups (people who returned with symptoms that necessitated further treatment). Adverse effects, as reported in one study, were diarrhoea (one participant, placebo group) and fatigue and reduced energy postoperatively (one participant, antibiotic group). Neither study reported quality of life measurements.Objective 1: systemic antibiotics versus placebo with surgical intervention and analgesics for symptomatic apical periodontitis or acute apical abscessTwo studies provided data for the comparison between systemic antibiotics (penicillin VK) and a matched placebo for adults with acute apical abscess or a symptomatic necrotic tooth when provided in conjunction with a surgical intervention. Participants in one study all underwent a total pulpectomy of the affected tooth, while participants in the other study had their tooth treated by either partial or total pulpectomy. Participants in both trials received oral analgesics. There were no statistically significant differences in participant-reported measures of pain or swelling at any of the time points assessed within the review. The MD for pain (short ordinal numerical scale 0 to 3) was -0.03 (95% CI -0.53 to 0.47) at 24 hours; 0.32 (95% CI -0.22 to 0.86) at 48 hours; and 0.08 (95% CI -0.38 to 0.54) at 72 hours. The SMD for swelling was 0.27 (95% CI -0.23 to 0.78) at 24 hours; 0.04 (95% CI -0.47 to 0.55) at 48 hours; and 0.02 (95% CI -0.49 to 0.52) at 72 hours. The body of evidence was assessed as at very low quality.Objective 2: systemic antibiotics without surgical intervention for adults with symptomatic apical periodontitis or acute apical abscessWe found no studies that compared the effects of systemic antibiotics with a matched placebo delivered without a surgical intervention for symptomatic apical periodontitis or acute apical abscess in adults.
AUTHORS' CONCLUSIONS
There is very low-quality evidence that is insufficient to determine the effects of systemic antibiotics on adults with symptomatic apical periodontitis or acute apical abscess.
Topics: Acute Disease; Adult; Anti-Bacterial Agents; Humans; Penicillin V; Periapical Abscess; Periapical Periodontitis; Pulpectomy; Randomized Controlled Trials as Topic; Toothache
PubMed: 30259968
DOI: 10.1002/14651858.CD010136.pub3