Carlos Zaror

Autologous platelet‐rich plasma for treating chronic wounds

BACKGROUNDnAutologous platelet-rich plasma (PRP) is a treatment that contains fibrin and high concentrations of growth factors with the potential to improve the healing of chronic wounds. This is the first update of a review first published in 2012.nnnOBJECTIVESnTo determine whether autologous PRP promotes the healing of chronic wounds.nnnSEARCH METHODSnIn June 2015, for this first update, we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library): Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE; and EBSCO CINAHL. We also searched for ongoing and unpublished clinical trials in the WHO International Clinical Trials Registry Platform (ICTRP) (searched January 2015). We did not impose any restrictions with respect to language, date of publication, or study setting.nnnSELECTION CRITERIAnWe included randomised controlled trials (RCTs) that compared autologous PRP with placebo or alternative treatments for any type of chronic wound in adults. We did not apply any date or language restrictions.nnnDATA COLLECTION AND ANALYSISnWe used standard Cochrane methodology, including two reviewers independently selecting studies for inclusion, extracting data, and assessing risk of bias.nnnMAIN RESULTSnThe search identified one new RCT, making a total of 10 included RCTs (442 participants, 42% women). The median number of participants per RCT was 29 (range 10 to 117). Four RCTs recruited people with a range of chronic wounds; three RCTs recruited people with venous leg ulcers, and three RCTs considered foot ulcers in people with diabetes. The median length of treatment was 12 weeks (range 8 to 40 weeks).It is unclear whether autologous PRP improves the healing of chronic wounds generally compared with standard treatment (with or without placebo) (risk ratio (RR) 1.19, 95% confidence interval (CI) 0.95 to 1.50; I(2) = 27%, low quality evidence, 8 RCTs, 391 participants). Autologous PRP may increase the healing of foot ulcers in people with diabetes compared with standard care (with or without placebo) (RR 1.22, 95% CI 1.01 to 1.49; I(2) = 0%, low quality evidence, 2 RCTs, 189 participants). It is unclear if autologous PRP affects the healing of venous leg ulcers (RR 1.02, 95% CI 0.81 to 1.27; I(2) = 0% ). It is unclear if there is a difference in the risk of adverse events in people treated with PRP or standard care (RR 1.05, 95% CI 0.29 to 3.88; I(2) = 0%, low quality evidence from 3 trials, 102 participants).nnnAUTHORS CONCLUSIONSnPRP may improve the healing of foot ulcers associated with diabetes, but this conclusion is based on low quality evidence from two small RCTs. It is unclear whether PRP influences the healing of other chronic wounds. The overall quality of evidence of autologous PRP for treating chronic wounds is low. There are very few RCTs evaluating PRP, they are underpowered to detect treatment effects, if they exist, and are generally at high or unclear risk of bias. Well designed and adequately powered clinical trials are needed.

Success Rate of Autotransplantation of Teeth With an Open Apex: Systematic Review and Meta-Analysis

PURPOSEnThe aim of the present study was to determine the success rate of autotransplanted permanent teeth with an open apex and to identify the most influential prognostic factors.nnnMATERIALS AND METHODSnA systematic search of the MEDLINE, EMBASE, LILACS, and SciELO databases was conducted for January 1990 to August 2015. The study eligibility criteria were primary studies that had evaluated patients with autotransplantation with an open apex, with or without preparation of the socket, and a minimum of 12xa0months of follow-up. The principal outcome was the success rate of autotransplanted teeth with an open apex. Two of us independently performed the selection process and data extraction. The Effective Public Health Practice Projects Quality Assessment Tool was used for the quality assessment of the studies. The odds ratio (OR) was calculated, with the 95% confidence interval (CI).nnnRESULTSnA total of 21 studies were included in the present analysis. Of the 21 studies, 10 were retrospective and 11 were prospective. All the studies were of weak methodologic quality. The overall success rate was 89.68%, the survival rate was 98.21%, and the mean follow-up period was 6xa0years, 3xa0months (standard deviation 5.81xa0years). Among the prognostic factors analyzed, the premolars had a lower failure risk than did the molars (OR, 0.46; 95% CI, 0.25 to 0.84). The stage of development of the root and the autotransplantation receptor site showed no statistically significant differences.nnnCONCLUSIONSnThe overall success rate and survival were high, despite the methodologic limitations of the included studies. Further study is needed of the prognostic factors that influence the success of autotransplantation with an open apex.

Validity and reliability of the T-Scan®III for measuring force under laboratory conditions

Although measuring bite force is an important indicator of the health of the masticatory system, few commercially available transducers have been validated for routine clinical use. T-Scan(®) III Occlusal Analysis System allows to record the bite force distribution, indicating its relative intensity and occlusal timing. Nevertheless, even fewer studies have evaluated the validity and reliability of the latest generation of the T-Scan(®) occlusal analysis system. To determine the validity and reliability of the T-Scan(®) III system when measuring total absolute bite force under laboratory conditions. Known forces were applied to 18 T-Scan(®) III sensors, which were classified into two groups differentiated by their production series. Both Lins concordance correlation coefficient (CCC) and the intra-class correlation coefficient (ICC) were used to assess the systems reliability and validity. Considering all the sensors studied, a substantial level (Lins CCC 0·969) and a very good level of reliability (CCI 0·994) were obtained. When evaluating the validity of the system, a poor (Lins CCC 0·530) and moderate (ICC 0·693) agreement were also obtained. The main factor that negatively influenced the validity of the T-Scan(®) III under these study conditions was the significant difference in the behaviour of the two sensor groups. The T-Scan(®) III showed a high degree of reliability when used to perform consecutive measurements. However, the system showed an insufficient degree of validity for measuring absolute force when estimating total occlusal force under laboratory conditions.

Atraumatic restorative treatment versus conventional restorative treatment for managing dental caries.

BACKGROUNDnDental caries is a sugar-dependent disease that damages tooth structure and, due to loss of mineral components, may eventually lead to cavitation. Dental caries is the most prevalent disease worldwide and is considered the most important burden of oral health. Conventional treatment methods (drill and fill) involve the use of rotary burs under local anaesthesia. The need for an electricity supply, expensive handpieces and highly trained dental health personnel may limit access to dental treatment, especially in underdeveloped regions.To overcome the limitations of conventional restorative treatment, the Atraumatic Restorative Treatment (ART) was developed, mainly for treating caries in children living in under-served areas of the world where resources and facilities such as electricity and trained manpower are limited. ART is a minimally invasive approach which involves removal of decayed tissue using hand instruments alone, usually without use of anaesthesia and electrically driven equipment, and restoration of the dental cavity with an adhesive material (glass ionomer cement (GIC), composite resins, resin-modified glass-ionomer cement (RM-GICs) and compomers).nnnOBJECTIVESnTo assess the effects of Atraumatic Restorative Treatment (ART) compared with conventional treatment for managing dental caries lesions in the primary and permanent teeth of children and adults.nnnSEARCH METHODSnCochrane Oral Healths Information Specialist searched the following databases: Cochrane Oral Healths Trials Register (to 22 February 2017), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2017, Issue 1), MEDLINE Ovid (1946 to 22 February 2017), Embase Ovid (1980 to 22 February 2017), LILACS BIREME Virtual Health Library (Latin American and Caribbean Health Science Information database; 1982 to 22 February 2017) and BBO BIREME Virtual Health Library (Bibliografia Brasileira de Odontologia; 1986 to 22 February 2017). 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.nnnSELECTION CRITERIAnWe included randomised controlled trials (RCTs) with at least six months follow-up that compared the effects of ART with a conventional restorative approach using the same or different restorative dental materials to treat caries lesions.nnnDATA COLLECTION AND ANALYSISnTwo review authors independently screened search results, extracted data from included studies and assessed the risk of bias in those studies. We used standard methodological procedures expected by Cochrane to evaluate risk of bias and synthesise data. Where pooling was appropriate we conducted meta-analyses using the random-effects model. We assessed the quality of the evidence using GRADE criteria.nnnMAIN RESULTSnWe included a total of 15 eligible studies randomising 3760 participants in this review. The age of participants across the studies ranged from 3 to 101 years, with a mean of 25.42 years. 48% of participants were male. All included studies were published between 2002 and 2016. Two of the 15 studies declared that the financial support was from companies that manufacture restorative material. Five studies were individually randomised parallel-group studies; six were cluster-randomised parallel-group studies; and four were randomised studies that used a split-mouth design. Eleven studies evaluated the effects of ART on primary teeth only, and four on permanent teeth. The follow-up period of the included studies ranged from 6 months to 36 months. We judged all studies to be at high risk of bias.For the main comparison of ART compared to conventional treatment using the same material: all but two studies used high-viscosity glass ionomer (H-GIC) as the restorative material; one study used a composite material; and one study used resin-modified glass ionomer cement (RM-GIC)).Compared to conventional treatment using H-GIC, ART may increase the risk of restoration failure in the primary dentition, over a follow-up period from 12 to 24 months (OR 1.60, 95% CI 1.13 to 2.27, five studies; 643 participants analysed; low-quality evidence). Our confidence in this effect estimate is limited due to serious concerns over risk of performance and attrition bias. For this comparison, ART may reduce pain during procedure compared with conventional treatment (MD -0.65, 95% CI -1.38 to 0.07; 40 participants analysed; low-quality evidence)Comparisons of ART to conventional treatment using composite or RM-GIC were downgraded to very low quality due to indirectness, imprecision and high risk of performance and attrition bias. Given the very low quality of the evidence from single studies, we are uncertain about the restoration failure of ART compared with conventional treatment using composite over a 24-month follow-up period (OR 1.11, 95% CI 0.54 to 2.29; one study; 57 participants) and ART using RM-GIC in the permanent teeth of older adults with root caries lesions over a six-month follow-up period (OR 2.71, 95% CI 0.94 to 7.81; one study; 64 participants).No studies reported on adverse events or costs.nnnAUTHORS CONCLUSIONSnLow-quality evidence suggests that ART using H-GIC may have a higher risk of restoration failure than conventional treatment for caries lesions in primary teeth. The effects of ART using composite and RM-GIC are uncertain due to the very low quality of the evidence and we cannot rely on the findings. Most studies evaluated the effects of ART on the primary dentition.Well-designed RCTs are required that report on restoration failure at clinically meaningful time points, as well as participant-reported outcomes such as pain and discomfort. Due to the potential confounding effects from the use of different dental materials, a robust body of evidence on the effects of ART compared with conventional treatment using the same restoration material is necessary. We identified four ongoing trials that could provide further insights into this area.

Morphology of the Physiological Apical Foramen in Maxillary and Mandibular First Molars

Information regarding the anatomy of the physiological apical foramen is limited. Knowing its diameter and shapes contributes to clinical work, specifically to the cleaning and shaping of the apical third. The aim of this ex vivo study was to determine the minimum and maximum diameters and shape of the physiological apical foramen in the roots of maxillary and mandibular first molars. A descriptive study was conducted on 89 recently extracted first molars. Roots 3-5 mm from the apex were sectioned and prepared for analysis at 40× magnification. The minimum and maximum diameters of each physiological foramen were measured using the program Motic Images plus 2.0 ML. The shape of the foramina, classified as round, oval or irregular, was determined by the difference between the maximum and minimum diameters. A total of 174 physiological foramina were analyzed. The average of the minimum and maximum diameters was between 0.24-0.33 mm in maxillary first molars and between 0.25-0.33 mm in mandibular first molars. In maxillary molars, the most common shape of the foramen was oval (50%), then irregular (32%), then round (18%). In mandibular molars, the oval shape was also the most frequent (59%), followed by irregular (23%) and round (18%). The findings of this study regarding the morphology of physiological apical foramina in first molars make it easier for the operator to choose the appropriately-sized instruments to perform endodontic therapy successfully.

Assessment of Mesial Root Morphology and Frequency of MB2 Canals in Maxillary Molars using Cone Beam Computed Tomography

Determinar la morfologia del sistema de canales de la raiz mesial de molares maxilares y la frecuencia del canal MB2 usando tomografia computadorizada de haz conico (TCHC). Un total de 1374 dientes, primeros molares maxilares (1MS, n= 802) y segundos molares maxilares (2MS, n= 572) de 508 pacientes Chilenos entre 8 y 77 anos fueron evaluados a traves de la TCHC. Se evaluo la raiz mesiobucal en todos sus tercio. La clasificacion de Vertucci fue utilizada para determinar la morfologia del sistema de canales. Los datos fueron analizados con los test Chi-Cuadrado de Pearson y la prueba de tendencia de Cuzick. La frecuencia del canal MB2 para el 1MS fue 73,44% y el 2MS 42,48%. La morfologia mas frecuente en el 1MS y 2MS fueron el tipo II y I de Vertucci, respectivamente. No se encontro asociacion significativa entre la frecuencia y el lado o sexo (p>0,005). Una asociacion positive fue encontrada a medida que aumentaba la edad en ambos 1MS y 2MS (p<0,001 y p= 0,023, respectivamente). Dada la complejidad de la anatomia de la raiz mesiobucal y la frecuente presencia del canal MB2, el clinico debe asumir la existencia de dos canales en esta raiz. La TCHC es una buena manera de identificar tempranamente el canal en los diferentes tercio radiculares.

Ácido Hipocloroso: una Nueva Alternativa como Agente Antimicrobiano y para la Proliferación Celular para Uso en Odontología

El acido hipocloroso (HOCl) es un potente antimicrobiano no antibiotico utilizado en medicina clinica para el control de infecciones y reparacion de heridas. In vivo el HOCl es sintetizado por celulas del sistema inmune para el control del agente patogeno durante la fagocitosis y ha sido sintetizado y estabilizado en el laboratorio con potenciales aplicaciones profilacticas y terapeuticas en medicina humana. El efecto antimicrobiano, antinflamatorio y en la proliferacion celular lo hacen una sustancia que debe ser mas evaluada para uso clinico en otras areas de salud. Existe un interes en el desarrollo de nuevas sustancias antimicrobianas de uso topico en odontologia para el control del biofilm dental, la inflamacion gingival y para la cicatrizacion de heridas de la mucosa oral. Se presenta una revision de la literatura de los principales efectos del HOCl que sustentan su investigacion y uso en odontologia.

Dental caries prevention in children and adolescents: a systematic quality assessment of clinical practice guidelines

ObjectivesTo evaluate the quality of clinical practice guidelines (CPGs) for dental caries prevention in children and adolescentsMaterials and methodsWe performed a systematic search of CPGs on caries preventive measures between 2005 and 2016. We searched MEDLINE, EMBASE, LILACS, TripDatabase, websites of CPG developers, compilers of CPGs, scientific societies and ministries of health. We included CPGs with recommendations on sealants, fluorides and oral hygiene. Three reviewers independently assessed the included CPGs using the AGREE II instrument. We calculated the standardised scores for the six domains and made a final recommendation about each CPG. Also, we calculated the overall agreement among calibrated reviewers with the intraclass correlation coefficient (ICC).ResultsTwenty-two CPGs published were selected from a total of 637 references. Thirteen were in English and nine in Spanish. The overall agreement between reviewers was very good (ICCu2009=u20090.90; 95%CI 0.89–0.92). The mean score for each domain was the following: Scope and purpose 89.6u2009±u200912%; Stakeholder involvement 55.0u2009±u200915.6%; Rigour of development 64.9u2009±u200921.2%; Clarity of presentation 84.8u2009±u200914.1%; Applicability 30.6u2009±u200931.5% and Editorial independence 59.3u2009±u200925.5%. Thirteen CPGs (59.1%) were assessed as “recommended”, eight (36.4%) “recommended with modifications” and one (4.5%) “not recommended”.ConclusionsThe overall quality of CPGs in caries prevention was moderate. The domains with greater deficiencies were Applicability, Stakeholder involvement and Editorial independence.Clinical relevanceClinicians should use the best available CPGs in dental caries prevention to provide optimal oral health care to patients.

Effectiveness of Low-Level Laser Therapy in Reducing Orthodontic Pain: A Systematic Review and Meta-Analysis

Objectives To assess the effectiveness of low-level laser therapy (LLLT) in reducing orthodontic pain after the application of orthodontic force (OF). Methods A systematic search was conducted in the MEDLINE, EMBASE, Scopus, Cochrane Library, Web of Science, and EBSCOhost databases. The study included randomized clinical trials (RCT) which analysed the effectiveness of LLLT in reducing orthodontic pain assessed at 24 and 72u2009hrs after the application of OF. The risk of bias of the eligible trials was assessed using the Cochrane Collaborations risk of bias tool. Standard mean difference was calculated and pooled by meta-analysis using random effect models. Results Of 467 identified articles, 20 RCT were finally included. In the risk of bias assessments, 13 studies presented a high risk, 5 an unclear risk, and 2 a low risk. The meta-analysis showed that in patients treated with laser versus placebo there was a difference in favour of LLLT in spontaneous pain 24 and 72u2009hrs after the installation of light archwires and spontaneous pain and chewing pain 24 and 72u2009hrs after the installation of elastomeric separators. Conclusions LLLT proved to be effective in promoting a reduction in spontaneous and chewing pain after the application of OF; however, the poor quality of the evidence requires these results to be treated with caution.

Apixaban was cost-effective vs. acenocoumarol in patients with nonvalvular atrial fibrillation with moderate to severe risk of embolism in Chile

OBJECTIVEnNonvalvular atrial fibrillation (NVAF) is a risk factor for ischemic stroke and systemic embolism. New oral anticoagulants are currently available. The objective of this study was to assess the incremental cost-utility ratio (ICUR) for apixaban vs. acenocoumarol in patients treated in Chiles public health system.nnnSTUDY DESIGN AND SETTINGnWe assessed cost-utility from the payer perspective with a lifetime Markov model. Epidemiologic characteristics, costs, and utilities were obtained from a Chilean cohort; data were completed with information from international literature.nnnRESULTSnIncremental costs when using apixaban vs. acenocoumarol over a lifetime are CH