-
Journal of Dentistry May 2019The most commonly-accepted strategy for managing irreversible pulpitis, an irreversible condition of dental pulp inflammation, is root canal treatment, which is limited... (Meta-Analysis)
Meta-Analysis
OBJECTIVES
The most commonly-accepted strategy for managing irreversible pulpitis, an irreversible condition of dental pulp inflammation, is root canal treatment, which is limited by high costs and complex techniques. High success rates have been reported for the use of pulpotomy in managing pulp exposure resulting from extensive caries. The objective of the present work was to evaluate the effectiveness and cost-effectiveness of pulpotomy and associated medicaments in saving permanent teeth with pulp exposure resulting from extensive caries.
SOURCES
Multiple databases were searched on January 12, 2019, without limitations on the language or year of publication.
STUDY SELECTION
Randomized controlled trials comparing pulpotomy with alternative treatments, or comparing two or more medicaments in pulpotomy for permanent teeth with carious pulp exposure were included.
DATA
Seventeen studies reported in 21 articles were included. Intention-to-treat analyses on studies comparing pulpotomy and other treatment modalities tended to favor pulpotomy. Meta-analysis was not performed on comparisons of pulpotomy and other treatments because of the limited number of studies. Most evidence on comparisons among different pulpotomy medicaments was found in trials comparing mineral trioxide aggregate (MTA) and calcium hydroxide, with the results of meta-analyses favoring MTA. Data were insufficient to determine the cost-effectiveness of successful modality.
CONCLUSIONS
Pulpotomy is a prospective substitute for root canal treatment in managing permanent teeth with carious pulp exposures, even in permanent teeth with irreversible pulpitis. Large, well-designed trials comparing pulpotomy with other treatments in terms of cost-effectiveness should be informative.
CLINICAL SIGNIFICANCE
The success of pulpotomy in managing irreversible pulpitis challenges the rhetoric that irreversible pulpitis can only be managed by root canal treatment. Cost-effectiveness analysis rather than analysis on effectiveness of treatment outcome alone should be considered in all health care domains to evaluate the benefits of alternative treatment options.
Topics: Aluminum Compounds; Calcium Compounds; Calcium Hydroxide; Dental Caries; Dentition, Permanent; Drug Combinations; Humans; Oxides; Prospective Studies; Pulpitis; Pulpotomy; Silicates; Treatment Outcome
PubMed: 30981748
DOI: 10.1016/j.jdent.2019.03.010 -
The Cochrane Database of Systematic... Aug 2018Phosphate binders are used to reduce positive phosphate balance and to lower serum phosphate levels for people with chronic kidney disease (CKD) with the aim to prevent... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Phosphate binders are used to reduce positive phosphate balance and to lower serum phosphate levels for people with chronic kidney disease (CKD) with the aim to prevent progression of chronic kidney disease-mineral and bone disorder (CKD-MBD). This is an update of a review first published in 2011.
OBJECTIVES
The aim of this review was to assess the benefits and harms of phosphate binders for people with CKD with particular reference to relevant biochemical end-points, musculoskeletal and cardiovascular morbidity, hospitalisation, and death.
SEARCH METHODS
We searched the Cochrane Kidney and Transplant Register of Studies up to 12 July 2018 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov.
SELECTION CRITERIA
We included randomised controlled trials (RCTs) or quasi-RCTs of adults with CKD of any GFR category comparing a phosphate binder to another phosphate binder, placebo or usual care to lower serum phosphate. Outcomes included all-cause and cardiovascular death, myocardial infarction, stroke, adverse events, vascular calcification and bone fracture, and surrogates for such outcomes including serum phosphate, parathyroid hormone (PTH), and FGF23.
DATA COLLECTION AND ANALYSIS
Two authors independently selected studies for inclusion and extracted study data. We applied the Cochrane 'Risk of Bias' tool and used the GRADE process to assess evidence certainty. We estimated treatment effects using random-effects meta-analysis. Results were expressed as risk ratios (RR) for dichotomous outcomes together with 95% confidence intervals (CI) or mean differences (MD) or standardised MD (SMD) for continuous outcomes.
MAIN RESULTS
We included 104 studies involving 13,744 adults. Sixty-nine new studies were added to this 2018 update.Most placebo or usual care controlled studies were among participants with CKD G2 to G5 not requiring dialysis (15/25 studies involving 1467 participants) while most head to head studies involved participants with CKD G5D treated with dialysis (74/81 studies involving 10,364 participants). Overall, seven studies compared sevelamer with placebo or usual care (667 participants), seven compared lanthanum to placebo or usual care (515 participants), three compared iron to placebo or usual care (422 participants), and four compared calcium to placebo or usual care (278 participants). Thirty studies compared sevelamer to calcium (5424 participants), and fourteen studies compared lanthanum to calcium (1690 participants). No study compared iron-based binders to calcium. The remaining studies evaluated comparisons between sevelamer (hydrochloride or carbonate), sevelamer plus calcium, lanthanum, iron (ferric citrate, sucroferric oxyhydroxide, stabilised polynuclear iron(III)-oxyhydroxide), calcium (acetate, ketoglutarate, carbonate), bixalomer, colestilan, magnesium (carbonate), magnesium plus calcium, aluminium hydroxide, sucralfate, the inhibitor of phosphate absorption nicotinamide, placebo, or usual care without binder. In 82 studies, treatment was evaluated among adults with CKD G5D treated with haemodialysis or peritoneal dialysis, while in 22 studies, treatment was evaluated among participants with CKD G2 to G5. The duration of study follow-up ranged from 8 weeks to 36 months (median 3.7 months). The sample size ranged from 8 to 2103 participants (median 69). The mean age ranged between 42.6 and 68.9 years.Random sequence generation and allocation concealment were low risk in 25 and 15 studies, respectively. Twenty-seven studies reported low risk methods for blinding of participants, investigators, and outcome assessors. Thirty-one studies were at low risk of attrition bias and 69 studies were at low risk of selective reporting bias.In CKD G2 to G5, compared with placebo or usual care, sevelamer, lanthanum, iron and calcium-based phosphate binders had uncertain or inestimable effects on death (all causes), cardiovascular death, myocardial infarction, stroke, fracture, or coronary artery calcification. Sevelamer may lead to constipation (RR 6.92, CI 2.24 to 21.4; low certainty) and lanthanum (RR 2.98, CI 1.21 to 7.30, moderate certainty) and iron-based binders (RR 2.66, CI 1.15 to 6.12, moderate certainty) probably increased constipation compared with placebo or usual care. Lanthanum may result in vomiting (RR 3.72, CI 1.36 to 10.18, low certainty). Iron-based binders probably result in diarrhoea (RR 2.81, CI 1.18 to 6.68, high certainty), while the risks of other adverse events for all binders were uncertain.In CKD G5D sevelamer may lead to lower death (all causes) (RR 0.53, CI 0.30 to 0.91, low certainty) and induce less hypercalcaemia (RR 0.30, CI 0.20 to 0.43, low certainty) when compared with calcium-based binders, and has uncertain or inestimable effects on cardiovascular death, myocardial infarction, stroke, fracture, or coronary artery calcification. The finding of lower death with sevelamer compared with calcium was present when the analysis was restricted to studies at low risk of bias (RR 0.50, CI 0.32 to 0.77). In absolute terms, sevelamer may lower risk of death (all causes) from 210 per 1000 to 105 per 1000 over a follow-up of up to 36 months, compared to calcium-based binders. Compared with calcium-based binders, lanthanum had uncertain effects with respect to all-cause or cardiovascular death, myocardial infarction, stroke, fracture, or coronary artery calcification and probably had reduced risks of treatment-related hypercalcaemia (RR 0.16, CI 0.06 to 0.43, low certainty). There were no head-to-head studies of iron-based binders compared with calcium. The paucity of placebo-controlled studies in CKD G5D has led to uncertainty about the effects of phosphate binders on patient-important outcomes compared with placebo.It is uncertain whether the effects of binders on clinically-relevant outcomes were different for patients who were and were not treated with dialysis in subgroup analyses.
AUTHORS' CONCLUSIONS
In studies of adults with CKD G5D treated with dialysis, sevelamer may lower death (all causes) compared to calcium-based binders and incur less treatment-related hypercalcaemia, while we found no clinically important benefits of any phosphate binder on cardiovascular death, myocardial infarction, stroke, fracture or coronary artery calcification. The effects of binders on patient-important outcomes compared to placebo are uncertain. In patients with CKD G2 to G5, the effects of sevelamer, lanthanum, and iron-based phosphate binders on cardiovascular, vascular calcification, and bone outcomes compared to placebo or usual care, are also uncertain and they may incur constipation, while iron-based binders may lead to diarrhoea.
Topics: Adult; Aged; Calcium; Calcium Compounds; Cause of Death; Chelating Agents; Chronic Disease; Chronic Kidney Disease-Mineral and Bone Disorder; Disease Progression; Fibroblast Growth Factor-23; Humans; Hypercalcemia; Iron Compounds; Lanthanum; Middle Aged; Parathyroid Hormone; Phosphorus; Polyamines; Randomized Controlled Trials as Topic; Renal Dialysis; Sevelamer
PubMed: 30132304
DOI: 10.1002/14651858.CD006023.pub3 -
Journal of the American Dental... Oct 2018The authors of this systematic review aimed to compare the effects of pulp-capping materials on hard-tissue barrier formation using histologic assessments. (Meta-Analysis)
Meta-Analysis
BACKGROUND
The authors of this systematic review aimed to compare the effects of pulp-capping materials on hard-tissue barrier formation using histologic assessments.
TYPE OF STUDIES REVIEWED
The authors included randomized controlled trials and controlled clinical trials in humans, with vital therapies performed on healthy permanent teeth undergoing experimental mechanical pulp exposures. They searched electronically in the PubMed, Cochrane, Embase, and Summon databases and carried out a manual search. Twenty-seven full-text articles were eligible for inclusion in the systematic review. After data extraction, the authors performed 2 sets of meta-analyses with odds ratios (OR) and their 95% confidence intervals (CI) on 22 studies. Ten studies compared mineral trioxide aggregate (MTA) with calcium hydroxide (CH), and 12 compared bonding agents with CH. The authors assessed bias by means of Cochrane Collaboration's tool for assessing risk, funnel plots, and Harbord test.
RESULTS
The use of MTA was associated with a higher rate of hard-tissue barrier formation than CH. The OR comparing the 2 groups was 2.45 (95% CI, 1.39 to 4.29; P = .002). Use of bonding agents was associated with a lower rate of hard-tissue barrier formation than CH. The OR comparing the 2 groups was 0.02 (95% CI, 0.01 to 0.05; P < .001).
CONCLUSIONS AND PRACTICAL IMPLICATIONS
The results suggest that MTA and CH have positive effects on hard-tissue barrier formation. On the basis of the evidence, the authors conclude that MTA has better effects than CH regarding dental pulp protection in the capping of mechanical pulp exposures. Conversely, bonding agents are inferior to CH.
Topics: Aluminum Compounds; Calcium Compounds; Calcium Hydroxide; Dental Pulp; Dental Pulp Capping; Drug Combinations; Humans; Oxides; Silicates
PubMed: 30098704
DOI: 10.1016/j.adaj.2018.06.003 -
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 -
Clinical Oral Investigations Jul 2016We systematically assessed randomized controlled trials comparing direct pulp capping materials. (Meta-Analysis)
Meta-Analysis Review
OBJECTIVES
We systematically assessed randomized controlled trials comparing direct pulp capping materials.
METHODS
Trials comparing materials for direct capping and evaluating clinically and/or radiographically determined success after minimum 3 months were included. Two reviewers independently screened electronic databases (Medline, Central, Embase) and performed hand searches. Risk of bias was assessed and meta-analyses were performed, separated for dentition. Trial sequential analysis was used to assess risk of random errors. Strength of evidence was graded using the GRADE approach.
RESULTS
From a total of 453 identified studies, 11 (all with high risk of bias) investigating 1094 teeth (922 patients) were included. Six studies were on primary teeth (all with carious exposures) and five on permanent teeth (carious and artificial exposures). Mean follow-up was 14 months (range 3-24). Most studies used calcium hydroxide as control, comparing it to mineral trioxide aggregate (MTA) (three studies), bonding without prior etching/conditioning (two), or bonding with prior etching/conditioning, enamel matrix proteins, resin-modified glass ionomer cement, calcium sulfate, zinc oxide eugenol, corticosteroids, antibiotics, or formocresol (each in only one study). One study compared MTA and calcium-enriched cement. In permanent teeth, risk of failure was significantly decreased if MTA instead of calcium hydroxide was used (risk ratio (RR) [95 % confidence intervals (CI)] 0.59 [0.39/0.90]); no difference was found for primary teeth. Other comparisons did not find significant differences or were supported by only one study. No firm evidence was reached according to trial sequential analysis.
CONCLUSION
There is insufficient data to recommend or refute the use of a specific material. More long-term practice-based studies with real-life exposures are required.
CLINICAL RELEVANCE
To reduce risk of failure, dentists might consider using MTA instead of calcium hydroxide (CH) for direct capping. Current evidence is insufficient for definitive recommendations.
Topics: Aluminum Compounds; Calcium Compounds; Calcium Hydroxide; Dental Materials; Dental Pulp Capping; Drug Combinations; Humans; Oxides; Silicates
PubMed: 27037567
DOI: 10.1007/s00784-016-1802-7 -
Journal of the Formosan Medical... Jul 2016Calcium hydroxide and mineral trioxide aggregate (MTA) are used for inducing a calcific barrier at an open tooth root (apexification). The purpose of this study was to... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND/PURPOSE
Calcium hydroxide and mineral trioxide aggregate (MTA) are used for inducing a calcific barrier at an open tooth root (apexification). The purpose of this study was to compare the efficacy of calcium hydroxide and MTA for apexification of immature permanent teeth.
METHODS
Medline, Cochrane, EMBASE, and Google Scholar were searched until November 24, 2015, using the keywords apexification, permanent teeth, MTA, and calcium hydroxide.
RESULTS
Of 216 studies identified, four studies were included. There were no differences in the clinical success rate [pooled odds ratio (OR) = 3.03, 95% confidence interval (CI): 0.42-21.72, p = 0.271], radiographic success rate (pooled OR = 4.30, 95% CI: 0.45-41.36, p = 0.206), or apical barrier formation rate (pooled OR = 1.71, 95% CI: 0.59-4.96, p = 0.322) between calcium hydroxide and MTA groups. The time required for apical barrier formation was significantly less in the MTA group (pooled difference in means = -3.58, 95% CI: from -4.91 to -2.25, p < 0.001).
CONCLUSION
While both materials provide similar success rates, the shorter treatment time with MTA may translate into higher overall success rates because of better patient compliance.
Topics: Aluminum Compounds; Apexification; Calcium Compounds; Calcium Hydroxide; Dental Pulp Necrosis; Drug Combinations; Humans; Oxides; Patient Compliance; Root Canal Filling Materials; Silicates; Tooth Apex; Tooth Loss
PubMed: 26911724
DOI: 10.1016/j.jfma.2016.01.010 -
The Cochrane Database of Systematic... Nov 2015Bone disease is common in children with chronic kidney disease (CKD) and when untreated may result in bone deformities, bone pain, fractures and reduced growth rates.... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Bone disease is common in children with chronic kidney disease (CKD) and when untreated may result in bone deformities, bone pain, fractures and reduced growth rates. This is an update of a review first published in 2010.
OBJECTIVES
This review aimed to examine the benefits (improved growth rates, reduced risk of bone fractures and deformities, reduction in PTH levels) and harms (hypercalcaemia, blood vessel calcification, deterioration in kidney function) of interventions (including vitamin D preparations and phosphate binders) for the prevention and treatment of metabolic bone disease in children with CKD.
SEARCH METHODS
We searched the Cochrane Kidney and Transplant Specialised Register to 8 September 2015 through contact with the Trial's Search Co-ordinator using search terms relevant for this review.
SELECTION CRITERIA
We included randomised controlled trials (RCTs) comparing different interventions used to prevent or treat bone disease in children with CKD stages 2 to 5D.
DATA COLLECTION AND ANALYSIS
Data were assessed for study eligibility, risk of bias and extracted independently by two authors. Results were reported as risk ratios (RR) or risk differences (RD) with 95% confidence intervals (CI) for dichotomous outcomes. For continuous outcomes the mean difference (MD) or standardised mean difference (SMD) with 95% confidence intervals (CI) was used. Statistical analyses were performed using the random-effects model.
MAIN RESULTS
This review included 18 studies (576 children); three new studies were added for this update. Adequate sequence generation and allocation concealment were reported in 12 and 11 studies respectively. Only four studies reported blinding of children, investigators or outcome assessors. Nine studies were at low risk of attrition bias and 12 studies were at low risk of selective reporting bias.Eight different interventions were compared. Two studies compared intraperitoneal (IP) with oral calcitriol. PTH levels were significantly lower with IP compared with oral calcitriol (1 study: MD -501.00 pg/mL, 95% CI -721.54 to -280.46) but the number of children with abnormal bone histology did not differ between treatments. Three studies compared intermittent with daily oral calcitriol. The change in mean height SDS (1 study: MD 0.13, 95% CI -0.22 to 0.48) and the percentage fall in parathyroid hormone (PTH) levels at eight weeks (1 study: MD -5.50%, 95% CI -32.37 to 21.37) and 12 months (1 study: MD -6.00% 95% CI -25.27 to 13.27) did not differ between treatments.Four studies compared active vitamin D preparations (calcitriol, paricalcitol, 1α-hydroxyvitamin D) with placebo or no specific treatment. One study reported vitamin D preparations significantly reduced PTH levels (-55.00 pmol/L, 95% CI -83.03 to -26.97). There was no significant difference in hypercalcaemia risk with vitamin D preparations compared with placebo or no specific treatment (4 studies, 103 children: RD 0.08 mg/dL, 95% CI -0.08 to 0.24). However, there was heterogeneity (I(2) = 55%) with one study showing a significantly greater risk of hypercalcaemia with intravenous (IV) calcitriol administration. Two studies (97 children) compared calcitriol with other vitamin D preparations and both found no significant differences in growth between preparations.Two studies compared ergocalciferol in patients with CKD and vitamin D deficiency. Elevated PTH levels developed significantly later in ergocalciferol treated children (1 study: hazard ratio 0.30, 95% CI 0.09 to 0.93) though the number with elevated PTH levels did not differ between groups (1 study, 40 children: RR 0.33, 95% CI 0.11 to 1.05).Two studies compared calcium carbonate with aluminium hydroxide as phosphate binders. One study (17 children: MD -0.86 SDS, 95% CI -2.24 to 0.52) reported no significant difference in mean final height SDS between treatments. Three studies compared sevelamer with calcium-containing phosphate binders. There were no significant differences in the final calcium, phosphorus or PTH levels between binders. More episodes of hypercalcaemia occurred with calcium-containing binders. One study reported no significant differences between calcitriol and doxercalciferol in bone histology or biochemical parameters.
AUTHORS' CONCLUSIONS
Bone disease, assessed by changes in PTH levels, is improved by all vitamin D preparations. However, no consistent differences between routes of administration, frequencies of dosing or vitamin D preparations were demonstrated. Although fewer episodes of high calcium levels occurred with the non-calcium-containing phosphate binder, sevelamer, compared with calcium-containing binders, there were no differences in serum phosphorus and calcium overall and phosphorus values were reduced to similar extents. All studies were small with few data available on patient-centred outcomes (growth, bone deformities) and limited data on biochemical parameters or bone histology resulting in considerable imprecision of results thus limiting the applicability to the care of children with CKD.
Topics: Aluminum Hydroxide; Bone Density Conservation Agents; Bone Diseases, Metabolic; Calcitriol; Calcium; Calcium Carbonate; Child; Chronic Disease; Ergocalciferols; Humans; Kidney Diseases; Parathyroid Hormone; Phosphorus; Polyamines; Randomized Controlled Trials as Topic; Sevelamer; Vitamin D
PubMed: 26561037
DOI: 10.1002/14651858.CD008327.pub2 -
The Cochrane Database of Systematic... Sep 2015Heartburn is one of the most common gastrointestinal symptoms in pregnant women. It can occur in all trimesters of pregnancy. The symptoms of heartburn in pregnancy may... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Heartburn is one of the most common gastrointestinal symptoms in pregnant women. It can occur in all trimesters of pregnancy. The symptoms of heartburn in pregnancy may be frequent, severe and distressing, but serious complications are rare. Many interventions have been used for the treatment of heartburn in pregnancy. These interventions include advice on diet, lifestyle modification and medications. However, there has been no evidence-based recommendation for the treatment of heartburn in pregnancy.
OBJECTIVES
To assess the effects of interventions for relieving heartburn in pregnancy.
SEARCH METHODS
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 June 2015), ClinicalTrials.gov (2 March 2015), Asian & Oceanic Congress of Obstetrics & Gynaecology (AOCOG) conference proceedings (20-23 October 2013, Centara Grand & Bangkok Convention Centre, Bangkok, Thailand), and reference lists of retrieved studies.
SELECTION CRITERIA
Randomised controlled trials (RCTs) and quasi-RCTS of interventions for heartburn in pregnancy compared with another intervention, or placebo, or no intervention. Cluster-RCTs would have been eligible for inclusion but none were identified. We excluded studies available as abstracts only and those using a cross-over design.Interventions could include advice on diet, lifestyle modification and medications (such as antacids, sucralfate, histamine 2-receptor antagonists, promotility drugs and proton pump inhibitors (PPIs)).
DATA COLLECTION AND ANALYSIS
Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy.
MAIN RESULTS
We included nine RCTs involving 725 women. However, five trials did not contribute data. Four trials involving 358 women contributed data. Trials were generally at mixed risk of bias.We only identified data for three comparisons: pharmaceutical treatment versus placebo or no treatment; acupuncture versus no treatment and pharmacological intervention versus advice on dietary and lifestyle changes. Pharmaceutical treatment compared with placebo or no treatmentTwo trials evaluated any pharmaceutical treatment compared with placebo or no treatment. One trial examined a treatment rarely used nowadays (intramuscular prostigmine 0.5 mg versus placebo). One trial evaluated the effect of magnesium and aluminium hydroxide plus simethicone liquid and tablet compared with placebo. For the primary outcome of this review (relief of heartburn), women who received pharmaceutical treatment reported complete heartburn relief more often than women receiving no treatment or placebo (risk ratio (RR) 1.85, 95% confidence interval (CI) 1.36 to 2.50 in two RCTs of 256 women, I(2) = 0%, moderate-quality evidence). Data on partial relief of heartburn were heterogenous and showed no clear difference (average RR 1.35, 95% CI 0.38 to 4.76 in two RCTs of 256 women, very low-quality evidence). In terms of secondary outcomes, there was no clear difference in the rate of side effects between the pharmaceutical treatment group and the placebo/no treatment group (RR 0.63, 95% CI 0.21 to 1.89 in two RCTs of 256 women, very low-quality evidence). Pharmacological intervention versus advice on dietary and lifestyle choicesOne study compared 1 g of sucralfate with advice on dietary and lifestyle choices in treating heartburn. More women in the sucralfate group experienced complete relief of heartburn compared to women who received advice on diet and lifestyle choices (RR 2.41, 95% CI 1.42 to 4.07; participants = 65; studies = one). The only secondary outcome of interest addressed by this trial was side effects. The evidence was not clear on intervention side effects rate between the two groups (RR 1.74, 95% CI 0.07 to 41.21; participants = 66; studies = one). There was only one instance of side effects in the pharmacological group. Acupuncture compared with no treatmentOne trial evaluated acupuncture compared with no treatment but did not report data relating to this review's primary outcome (relief of heartburn). In terms of secondary outcomes, there was no difference in the rate of side effects between women who had acupuncture and women who had no treatment (RR 2.43, 95% CI 0.11 to 55.89 in one RCT of 36 women). With regard to quality of life, women who had acupuncture reported improved ability to sleep (RR 2.80, 95% CI 1.14 to 6.86) and eat (RR 2.40, 95% CI 1.11 to 5.18 in one RCT of 36 women).The following secondary outcomes were not reported upon in any of the trials included in the review: miscarriage, preterm labour, maternal satisfaction, fetal anomalies, intrauterine growth restriction, low birthweight.
AUTHORS' CONCLUSIONS
There are no large-scale RCTs to assess heartburn relief in pregnancy. This review of nine small studies (which involved data from only four small studies) indicates that there are limited data suggesting that heartburn in pregnancy could be completely relieved by pharmaceutical treatment. Three outcomes were assessed and assigned a quality rating using the GRADE methods. Evidence from two trials for the outcome of complete relief of heartburn was assessed as of moderate quality. Evidence for the outcomes of partial heartburn relief and side effects was graded to be of very low quality. Downgrading decisions were based in part on the small size of the trials and on heterogenous and imprecise results.There are insufficient data to assess acupuncture versus no treatment and no data to assess other comparisons (miscarriage, preterm labour, maternal satisfaction, fetal anomalies, intrauterine growth restriction, low birthweight).Further RCTs are needed to fully evaluate the effectiveness of interventions for heartburn in pregnancy. Future research should also address other medications such as histamine 2-receptor antagonists, promotility drugs, proton pump inhibitors, and a raft-forming alginate reflux suppressant in treatment of heartburn in pregnancy. More research is needed on acupuncture and other complimentary therapies as treatments for heartburn in pregnancy. Future research should also evaluate any adverse outcomes, maternal satisfaction with treatment and measure pregnant women's quality of life in relation to the intervention.
Topics: Acupuncture Therapy; Adult; Aluminum Hydroxide; Antacids; Female; Heartburn; Humans; Magnesium Hydroxide; Neostigmine; Pregnancy; Pregnancy Complications; Randomized Controlled Trials as Topic; Sucralfate
PubMed: 26384956
DOI: 10.1002/14651858.CD011379.pub2 -
International Endodontic Journal Jun 2016The aim was to update a systematic review of pulp capping and partial pulpotomy by Olsson et al. (2006), by evaluating new evidence on formation of a hard tissue... (Review)
Review
The aim was to update a systematic review of pulp capping and partial pulpotomy by Olsson et al. (2006), by evaluating new evidence on formation of a hard tissue barrier after pulp capping and partial pulpotomy of experimental exposures in humans. PubMed (01-01-2005 to 01-03-2014) and CENTRAL were searched using specific keywords. Hand searches were made and the level of evidence for each included article was evaluated by the authors. The evidence of the conclusions was graded as strong, moderately strong, limited or insufficient. The initial search in PubMed yielded 215 abstracts. Hand searches of reference lists yielded no additional original scientific articles. After a selection process and interpretation, 22 articles were included and rated for level of evidence: no article was rated as high and seven as moderate. Overall the methodological quality of studies has improved since the previous systematic review was published in 2006. The conclusions are that there is limited scientific evidence that application of calcium hydroxide or mineral trioxide aggregate to an exposed pulp frequently results in formation of a hard tissue barrier, whereas adhesives or enamel matrix derivatives do not. There is insufficient scientific evidence that mineral trioxide aggregate promotes hard tissue formation more frequently than calcium hydroxide.
Topics: Aluminum Compounds; Calcium Compounds; Calcium Hydroxide; Dental Pulp Capping; Drug Combinations; Humans; Oxides; Pulpotomy; Silicates; Treatment Outcome
PubMed: 26059916
DOI: 10.1111/iej.12480 -
European Archives of Paediatric... Aug 2015The aim of this study was to evaluate the scientific evidence of pulpotomy in primary teeth comparing mineral troxide aggregate (MTA), calcium hydroxide, ferric... (Comparative Study)
Comparative Study Meta-Analysis Review
AIM
The aim of this study was to evaluate the scientific evidence of pulpotomy in primary teeth comparing mineral troxide aggregate (MTA), calcium hydroxide, ferric sulphate, and electrosurgery with formocresol.
METHODS
A systematic search using key words was conducted using seven databases up to December 10, 2013. Clinical articles in English, Portuguese and Spanish were selected, which were in accordance with the inclusion and exclusion criteria and the research objective of comparing whether pulpotomy performed with formocresol in primary teeth is more effective than other medicaments or techniques.
RESULTS
Out of the 12,515 publication initially identified, 30 clinical articles were included in the systematic review and analysed by four meta-analyses. The success rate of MTA (94.6 %) was higher than that of formocresol (87.4 %), with a statistically significant difference (OR = 0.39; 95 % CI = 0.25-0.62). Formocresol pulpotomy success was not statistically different from ferric sulphate or electrosurgery.
CONCLUSION
MTA was clinically and radiographically superior to formocresol for pulpotomy of primary teeth. The other alternatives to formocresol such as electrosurgery and ferric sulphate can be used instead of formocresol since they showed success similar to formocresol. In addition, there is no evidence to support calcium hydroxide for pulpotomies in primary teeth.
Topics: Aluminum Compounds; Calcium Compounds; Calcium Hydroxide; Drug Combinations; Electrosurgery; Ferric Compounds; Formocresols; Humans; Oxides; Pulpotomy; Root Canal Irrigants; Silicates; Tooth, Deciduous; Treatment Outcome
PubMed: 25833280
DOI: 10.1007/s40368-015-0174-z