Veerasamy Yengopal

Caries preventive effect of casein phosphopeptide-amorphous calcium phosphate (CPP-ACP): a meta-analysis

Objective. This systematic review with meta-analyses sought to answer the following question: “Does CPP-ACP [casein phosphopeptide-amorphous calcium phosphate], when introduced into the oral environment, provide any caries-preventive benefit superior to that of any other intervention or placebo?” Material and methods. Seven electronic databases were searched for trials relevant to the review question. Twelve articles were accepted after application of inclusion and exclusion criteria. Results. Of the accepted articles, five in situ randomized control trials (RCT) could be pooled for meta-analyses. During the short-term (7–21 days) in situ trials, participants wore appliances containing enamel slabs that were analyzed in the laboratory after exposure to CPP-ACP. The pooled in situ results showed a weighted mean difference (WMD) of the percentage remineralization scores in favor of chewing gum with 18.8 mg CPP-ACP as compared to chewing gum without CPP-ACP (WMD −8.01; 95% CI: −10.54 to −5.48; p = 0.00001), as well as compared to no intervention (WMD −13.56; 95% CI: −16.49 to −10.62; p = 0.00001). A significant higher remineralization effect was also observed after exposure to 10.0 mg CPP-ACP (−7.75; 95% CI: −9.84 to −5.66; p = 0.00001). One long-term in vivo RCT (24 months) with a large sample size (n = 2720) found that the odds of a tooth surfaces progressing to caries was 18% less in subjects who chewed sugar-free gum containing 54 mg CPP-ACP than in control subjects who chewed gum without CPP-ACP (p = 0.03). Conclusion. Within the limitations of this systematic review with meta-analysis, the results of the clinical in situ trials indicate a short-term remineralization effect of CPP-ACP. Additionally, the promising in vivo RCT results suggest a caries-preventing effect for long-term clinical CPP-ACP use. Further randomized control trials are needed in order to confirm these initial results in vivo.

Sugar-free chewing gum and dental caries: a systematic review

Objective: To appraise existing evidence for a therapeutic / anti-cariogenic effect of sugar-free chewing gum for patients. Method: 9 English and 2 Portuguese databases were searched using English and Portuguese keywords. Relevant articles in English, German, Portuguese and Spanish were included for review. Trials were excluded on lack of randomisation, control group, blinding and baseline data, drop out rate >33%, no statistical adjustment of baseline differences and no assessment of clinically important outcomes. Reviews were excluded on lack of information, article selection criteria, search strategy followed, search keywords, searched databases or lack of study-by-study critique tables. In cases of multiple reports from the same study, the report covering the longest period was included. Two reviewers independently reviewed and assessed the quality of accepted articles. Results: Thirty-nine articles were included for review. Thirty were excluded and 9 accepted. Of the 9 accepted, 2 trials of reasonable and good evidence value did not demonstrate any anti-cariogenic effect of sugar-free chewing gum. However, 7 articles, with 1 of strong, and 6 of good evidence value, demonstrated anti-cariogenic effects of chewing Sorbitol, Xylitol or Sorbitol/Xylitol gum. This effect can be ascribed to saliva stimulation through the chewing process, particularly when gum is used immediately after meals; the lack of sucrose and the inability of bacteria to metabolize polyols into acids. Conclusion: The evidence suggests that sugar-free chewing gum has a caries-reducing effect. Further well-designed randomised trials are needed to confirm these findings.

Caries-preventive effect of glass ionomer and resin-based fissure sealants on permanent teeth: An update of systematic review evidence

BackgroundThis article constitutes a partial update of the original systematic review evidence by Yengopal et al. from 15 January 2008 (published in the Journal of Oral Science in 2009) with primary focus on research quality in regard to bias risk in trials. Its aim is to update the existing systematic review evidence from the English literature as to whether caries occurrence on pits and fissures of teeth sealed with either GIC or resin is the same.MethodsIn addition to the 12 trials included during the original systematic review, 5 new trials were identified during the database search (up to 26 August 2010) and 2 further trials were included from a hand search and reference check. Of these, 3 trials were excluded and 16 were accepted for data extraction and quality assessment. The quality of accepted trials was assessed, using updated quality criteria, and the risk of bias was investigated in more depth than previously reported. In addition, the focus of quantitative synthesis was shifted to single datasets that were extracted from the accepted trials.ResultsTwenty-six dichotomous and 4 continuous datasets were extracted. Meta-analysis and cumulative meta-analysis were used in combining clinically homogenous datasets. The overall outcome of the computed datasets suggest no difference between the caries-preventive effects of GIC- and resin-based fissure sealants.ConclusionsThis overall outcome is in agreement with the conclusions of the original systematic review. Although the findings of the trials identified in this update may be considered to be less affected by attrition- and publication bias, their risk of selection- and detection-/performance bias is high. Thus, verification of the currently available results requires further high quality randomised control trials.

Therapeutic effect of glass‐ionomers: an overview of evidence

The requirements for an ideal restorative material include adhesion to tooth structure (enamel and dentine) and an ability to withstand the traumas of occlusion. However, some level of an anticaries effect is also desirable. After a long history of glass-ionomer cement (GIC) development, an evidence base in support of the therapeutic effect of GIC, particularly with regard to its anticaries effect, is emerging. This evidence is increasingly presented through systematic reviews of clinical GIC application and, to a certain extent, relates to a caries-preventive effect of the material itself. However, the strength of evidence supporting other aspects of GIC, such as a higher remineralizing effect, fluoride uptake in hard tooth tissue and fluoride release of GIC, is limited. Nevertheless, the results of these in situ and laboratory trials provide valuable insights into factors that facilitate understanding of the clinical efficacy of GIC.

Do oral lesions associated with HIV affect quality of life

OBJECTIVE To assess the impact of oral lesions on quality of life (QOL) in HIV-positive (HIV+) individuals using the Oral Health Impact Profile (OHIP). STUDY DESIGN This was a cross-sectional analytic study that compared 2 groups of HIV+ patients. Group 1 (n = 71) consisted of patients who presented with oral manifestations of HIV infection. Patients in group 2 (n = 79) were also HIV positive but had no oral lesions. The QOL measures were assessed by either simple frequency counts or the use of item weights. RESULTS Oral candidiasis was the most common oral lesion diagnosed. Patients in group 1 reported significantly greater impacts (P < .05) for all 7 subscales in OHIP. CONCLUSIONS Oral lesions associated with HIV infection negatively affect the oral health-related QOL in infected patients.

Validity of Sealant Retention as Surrogate for Caries Prevention – A Systematic Review

Introduction/Aim To appraise the clinical literature in determining whether loss of complete sealant retention as surrogate endpoint is directly associated with caries occurrence on sealed teeth as its clinical endpoint and to apply the appraised evidence in testing the null-hypothesis that the retention/caries ratio between different types of sealant materials (resin and glass-ionomer cement) is not statistically significant ( = Prentice criterion for surrogate endpoint validity). Methods Databases searched PubMed/Medline, Directory of Open Access Journals; IndMed, Scielo. Systematic reviews were checked for suitable trials. The search terms: “fiss* AND seal*” and “fissure AND sealant” were used. Article selection criteria were: clinical trial reporting on the retention and caries occurrence of resin and/or glass-ionomer cement (GIC) fissure sealed permanent molar teeth; minimum 24-month follow-up period; systematic review or meta-analysis. Datasets and information were extracted from accepted trials. The principle outcome measure was the ratio of Risk of loss of complete retention to the Risk of caries occurrence per sealant type (RCR). Risk of bias was assessed in trials and sensitivity analysis with regard to potential confounding factors conducted. The null-hypothesis was tested by graphical and statistical methods. Results The risk of loss of complete retention of sealant materials was associated with the risk of caries occurrence for resin but not for GIC based sealants. The difference between RCR values of the two sealant types was statistically significant (p<0.05). The null-hypothesis was rejected. Conclusions The current clinical evidence suggests that complete retention of pit and fissure sealants may not be a valid surrogate endpoint for caries prevention as its clinical endpoint. Further research is required to corroborate the current results.

Caries-preventive effect of resin-modified glass-ionomer cement (RM-GIC) versus composite resin: a quantitative systematic review.

AIM: To determine whether resin-modified glass-ionomer cement (RM-GIC), when compared with composite resins (CR), offers a significant caries-preventive effect. STUDY DESIGN: Quantitative systematic review. METHODS: Five databases were searched until 29 July 2010. Inclusion criteria were: relevant to review question related to orthodontic or restorative treatment; published in English; prospective clinical 2-arm study. Exclusion criteria were: no computable data reported; study groups not followed up in the same way. References of included articles were checked. The outcome measure was absence of carious lesions. Dichotomous datasets for both groups were extracted from accepted trials. Trials were assessed for selection-, detection/performance, attrition and publication bias. RESULTS: Of the 11 trials included, 6 were accepted and 24 datasets extracted; 17 datasets showed no difference after 4 weeks to >25 months. There were 7 datasets that favoured (p < 0.05) RM-GIC after 12 — 24 months. The results are limited by risk of selection-, detection-/performance bias and attrition bias. Risk of publication bias was identified. CONCLUSIONS: The overall results showed either no difference between the materials, or indicated that RM-GIC has a superior caries-preventive effect. The clinical meaning of this result remains uncertain due to risk of bias. High-quality randomised control trials are needed in order to answer the review question conclusively.

Predictive value of group I oral lesions for HIV infection.

OBJECTIVES Attendees presenting for treatment of acute illness at primary health care facilities in South Africa were assessed to determine the prevalence of human immunodeficiency virus (HIV) infection and the predictability of group I oral lesions (GOLs) for HIV infection. METHODS This was a cross-sectional analytical study. Patients >18 years of age were recruited and underwent an oral examination and a HIV test. RESULTS A total of 522 attendees were examined and the HIV prevalence was 40%. None of them were taking antiretroviral drugs. GOLs were diagnosed in 53% of HIV patients, with pseudomembranous and erythematous candidiasis being the most common (38% and 24%, respectively). The average odds and likelihood ratios for multiple lesions were high (32 and 30, respectively) and showed a strong correlation between GOLs and a positive HIV status. CONCLUSION The prevalence of HIV (40%) and GOLs (53%) was high. GOLs were useful markers of HIV infection, with multiple lesions being highly predictive of HIV infection.

Pulp response to resin-modified glass ionomer and calcium hydroxide cements in deep cavities: A quantitative systematic review

OBJECTIVE To quantitatively determine whether the pulp response to resin-modified glass ionomer cements placed in deep cavities differs from that generated by calcium hydroxide cement. SOURCES Five databases were searched for articles up to 31 May 2009. STUDY SELECTION INCLUSION CRITERIA titles/abstracts relevant to topic; published in English; two-arm longitudinal in vivo trial; containing computable dichotomous datasets for test and control group. EXCLUSION CRITERIA not all entered subjects accounted for at the end of the trial; subjects of both groups not followed up in the same way; trial on animal tissue. DATA One randomized and five non-randomized control trials, reporting on 1 and 17 datasets, respectively, were accepted. From non-randomized trials, the Relative Risk with 95% Confidence Interval of 13 datasets showed no statistically significant differences (p>0.05) and 4 showed a statistically significant difference between both materials. Meta-analysis of datasets from these trials found no difference between the inflammatory cell response after 30 days (0.87; 95%CI 0.59-1.26; p=0.46); 38% less inflammatory cell response with calcium hydroxide after 60 days (0.62; 95%CI 0.50-0.76; p<0.00001); higher number of intact odontoblasts beneath restored cavities after 381 days (0.56; 95%CI 0.38-0.82; p=0.0008). The results from the randomized control trial (1.40; 95%CI 0.92-2.14; p=0.11) indicated no difference in clinically identifiable pulp symptoms after two years. All trials showed limited internal validity due to selection bias. CONCLUSION No conclusive statement about the superiority of either type of material can yet be made. Further high-quality randomized control trials are needed.

Chlorhexidine for the prevention of alveolar osteitis

This systematic review assessed the efficacy of chlorhexidine for the prevention of alveolar osteitis and occurrence of adverse reactions. Databases were searched until 20 April 2011. Trial inclusion criteria were: titles/abstracts relevant to topic; prospective 2-arm (or more) clinical study design. Trial exclusion criteria were: not all entered subjects accounted for; subjects of both groups not followed up the same way; lack of computable data; chlorhexidine not the primary test agent; duplication of data; outcome of interest other than incidence of alveolar osteitis. Individual datasets were extracted from accepted articles. Bias risk in trials was assessed. 10 of 13 included trials were accepted. From these, 16 dichotomous datasets were extracted. Two of six application protocols favoured chlorhexidine over placebo: Single application of 0.2% chlorhexidine gel placed in the socket immediately after extraction versus placebo gel (RR 0.40; 95% CI: 0.18-0.90; p=0.03) and 0.12% chlorhexidine rinse applied on day of surgery and used twice daily for 7 days postoperatively versus placebo rinse (RR 0.50; 95% CI: 0.27-0.93; p=0.03). These results are negated due to high bias risk. Chlorhexidine did not cause higher adverse reactions than placebo. Further high-quality randomised control trials are needed.