Venkateshbabu Nagendrababu

Methodological and Reporting Quality of Systematic Reviews and Meta-analyses in Endodontics

Introduction: The aim of this systematic review (SR) was to evaluate the quality of SRs and meta‐analyses (MAs) in endodontics. Methods: A comprehensive literature search was conducted to identify relevant articles in the electronic databases from January 2000 to June 2017. Two reviewers independently assessed the articles for eligibility and data extraction. SRs and MAs on interventional studies with a minimum of 2 therapeutic strategies in endodontics were included in this SR. Methodologic and reporting quality were assessed using A Measurement Tool to Assess Systematic Reviews (AMSTAR) and Preferred Reporting Items for Systematic Review and Meta‐Analyses (PRISMA), respectively. The interobserver reliability was calculated using the Cohen kappa statistic. Statistical analysis with the level of significance at P < .05 was performed using Kruskal‐Wallis tests and simple linear regression analysis. Results: A total of 30 articles were selected for the current SR. Using AMSTAR, the item related to the scientific quality of studies used in conclusion was adhered by less than 40% of studies. Using PRISMA, 3 items were reported by less than 40% of studies, which were on objectives, protocol registration, and funding. No association was evident comparing the number of authors and country with quality. Statistical significance was observed when quality was compared among journals, with studies published as Cochrane reviews superior to those published in other journals. AMSTAR and PRISMA scores were significantly related. Conclusions: SRs in endodontics showed variability in both methodologic and reporting quality. HIGHLIGHTSThe overall methodologic quality and the reporting quality of included systematic reviews and meta‐analyses were found to be moderate.There was no significant difference in quality based on the number of authors and the country of study.A high correlation was found between A Measurement Tool to Assess Systematic Reviews (AMSTAR) and Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) quality assessment scores.AMSTAR and PRISMA are valuable tools that can help the authors to assess and improve the quality of systematic reviews and meta‐analyses.

Root canal irrigants influence the hydrophobicity and adherence of Staphylococcus epidermidis to root canal dentin: an in vitro study

Objectives To determine the effect of root canal irrigants on the hydrophobicity and adherence of Staphylococcus epidermidis (S. epidermidis) to root canal dentin in vitro. Materials and Methods Root dentin blocks (n = 60) were randomly divided into 4 groups based on the irrigation regimen: group 1, saline; group 2, 5.25% sodium hypochlorite (NaOCl); group 3, 5.25% NaOCl followed by 17% ethylenediaminetetraacetic acid (EDTA); group 4, same as group 3 followed by 2% chlorhexidine (CHX). The hydrophobicity of S. epidermidis to root dentin was calculated by cell surface hydrophobicity while the adherence was observed by fluorescence microscopy, and bacteria were quantified using ImageJ software (National Institutes of Health). Statistical analysis of the data was done using Kruskal-Wallis test and Mann-Whitney U test (p = 0.05). Results The hydrophobicity and adherence of S. epidermidis to dentin were significantly increased after irrigating with group 3 (NaOCl-EDTA) (p < 0.05), whereas in group 4 (NaOCl-EDTA-CHX) both hydrophobicity and adherence were significantly reduced (p < 0.05). Conclusions The adherence of S. epidermidis to dentin was influenced differently by root canal irrigants. Final irrigation with CHX reduces the bacterial adherence and may impact biofilm formation.

Efficacy of Biodentine and Mineral Trioxide Aggregate in Primary Molar Pulpotomies—A Systematic Review and Meta-Analysis With Trial Sequential Analysis of Randomized Clinical Trials

Objectives Pulpotomy is the favored treatment for pulp exposure in carious primary teeth. This review aimed to compare the success rates of biodentine (BD) and mineral trioxide aggregate (MTA) pulpotomies in primary molars using meta‐analysis (MA) and trial sequential analysis (TSA) and also to assess the quality of the results by Grading of Recommendations, Assessment, Development and Evaluation (GRADE). Methods PubMed, EBSCOhost, and Scopus databases were searched. Additional searching was performed in clinical trial registry, reference lists of systematic reviews, and textbooks. Randomized clinical trials (RCTs) published in the English language through October 2017 comparing the success of pulpotomies in vital primary molars with a follow‐up of at least 6 months were selected. Study selection, data extraction, and risk of bias assessment were performed. MA by random effects model, TSA, and GRADE were performed. Results Eight RCTs (n = 474) were included. Two RCTs had low risk of bias. No significant difference was observed between MTA and BD in clinical success at 6 months (risk ratio [RR], 1.00; 95% confidence interval [95% CI], 0.97–1.02; I2 = 0%), 12 months (RR, 1.00; 95% CI, 0.96–1.05; I2 = 0%), and 18 months (RR, 1.00; 95% CI, 0.93–1.08; I2 = 0%). No difference was observed in radiographic success at follow‐up of 6 months (RR, 0.99; 95% CI, 0.96–1.02; I2 = 0%), 12 months (RR, 1.02; 95% CI, 0.47–2.21; I2 = 0%), and 18 months (RR, 1.02; 95% CI, 0.91–1.15; I2 = 0%). TSA indicated lack of firm evidence for the results of the meta‐analytic outcomes on clinical and radiographic success. GRADE assessed the evidence from the MA comparing the effect of MTA and BD in pulpotomy to be of low quality. Conclusion BD and MTA have similar clinical and radiographic success rates based on limited and low‐quality evidence. Future high‐quality RCTs between MTA and BD is required to confirm the evidence.

Effect of Nonsteroidal Anti-inflammatory Drug as an Oral Premedication on the Anesthetic Success of Inferior Alveolar Nerve Block in Treatment of Irreversible Pulpitis: A Systematic Review with Meta-analysis and Trial Sequential Analysis

Introduction: Successful anesthesia with an inferior alveolar nerve block (IANB) is imperative for treating patients with irreversible pulpitis in mandibular teeth. This systematic review assessed the efficacy of nonsteroidal anti‐inflammatory drugs (NSAIDs) as oral premedications on the success of IANBs in irreversible pulpitis. Methods: Three databases were searched to identify randomized clinical trials (RCTs) published up until September 2017. Retrieved RCTs were evaluated using the revised Cochrane Risk of Bias Tool. The primary efficacy outcome of interest was the success rate of IANB anesthesia. Meta‐analytic estimates (risk ratio [RR] with 95% confidence intervals [CIs]) performed using a random effects model and publication bias determined using funnel plot analysis were assessed. Random errors were evaluated with trial sequential analyses, and the quality of evidence was appraised using a Grading of Recommendations, Assessment, Development and Evaluation approach. Results: Thirteen RCTs (N = 1034) were included. Eight studies had low risk of bias. Statistical analysis of good‐quality RCTs showed a significant beneficial effect of any NSAID in increasing the anesthetic success of IANBs compared with placebo (RR = 1.92; 95% CI, 1.55–2.38). Subgroup analyses showed a similar beneficial effect for ibuprofen, diclofenac, and ketorolac (RR = 1.83 [95% CI, 1.43–2.35], RR = 2.56 [95% CI, 1.46–4.50], and RR = 2.07 [95% CI, 1.47–2.90], respectively). Dose‐dependent ibuprofen >400 mg/d (RR = 1.85; 95% CI, 1.39–2.45) was shown to be effective; however, ibuprofen ≤400 mg/d showed no association (RR = 1.78; 95% CI, 0.90–3.55). TSA confirmed conclusive evidence for a beneficial effect of NSAIDs for IANB premedication. The Grading of Recommendations, Assessment, Development and Evaluation approach did not reveal any concerns regarding the quality of the results. Conclusions: Oral premedication with NSAIDs and ibuprofen (>400 mg/d) increased the anesthetic success of IANBs in patients with irreversible pulpitis. HIGHLIGHTSA systematic review of the effects of oral premedication for inferior alveolar nerve block identified 13 RCTs.NSAIDs increase inferior alveolar nerve block success in irreversible pulpitis.Trial sequential analysis confirmed meta‐analytic results.

Effectiveness of ultrasonically activated irrigation on root canal disinfection: a systematic review of in vitro studies

ObjectivesReduction of microbial load from the root canal systems is a pre-requisite for healing of lesions of endodontic origin. Such microbial reduction is influenced by the method of irrigant delivery and activation. The aim of this systematic review was to compare the effect of ultrasonically activated irrigation (UAI) with other irrigation techniques on the reduction of microorganisms during root canal disinfection.Materials and methodsThe research question was created based on the PICO strategy. Two reviewers independently performed a comprehensive literature search in electronic databases. Following application of inclusion and exclusion criteria to the selected articles, a systematic data extraction sheet was constructed. The selected articles were assessed using methodological quality scoring protocol. The risk of bias in selected studies was critically assessed by two reviewers.ResultsA total of 15 articles were included for the systematic review. The included studies were heterogeneous in study design; hence, meta-analysis was not performed. The overall risk of bias for the selected studies was moderate. Overall, UAI showed superior reduction of microbial counts, resulting in better disinfection compared to other irrigation systems chosen for comparison in this review.ConclusionThe use of UAI can bring about superior microbial reduction within the root canal system compared to other irrigant activation techniques.Clinical relevanceActivation of irrigants with ultrasonic brings about significant bacterial reduction from the root canal systems compared to other methods of irrigant activation and conventional syringe irrigation. This might help in improving the outcome of root canal treatment.

Effect of root canal debridement on inflammatory cytokine levels

In endodontic infections, inflammatory mediators such as cytokines are released, recruited and retained until the infection is eradicated. Root canal therapy is performed to prevent the spread of infection. The aim of this study was to investigate the effects of root canal debridement (cleaning and shaping) on periapical inflammation by measuring the levels of inflammatory cytokines, Interleukin-8 (IL-8) and Interleukin-10 (IL-10). The study includes twenty patients with pulp necrosis and asymptomatic apical periodontitis. Periradicular sample was collected using paper points before and after root canal debridement. Cytokine levels were determined by Sandwich Enzyme-Linked Immunosorbent Assay (ELISA). Data were analysed using paired t-test (PASW Statistics 18) (P = 0.05). All samples showed the presence of IL-8 and IL-10 prior to root canal debridement. Significantly reduced levels (P < 0.05) of IL-8 and IL-10 were detected after root canal debridement. In conclusion, root canal debridement significantly decreased the levels of the tested pro- and anti-inflammatory cytokine in the periradicular interstitial fluid.

Comparison of the Antibacterial Efficacy of Alexidine and Chlorhexidine Against Enterococcus Faecalis: An in Vitro Study

Introduction Root canal irrigants play an important role in reducing intracanal microorganisms, which in turn helps in achieving a successful outcome for the root canal treatment. Objective To compare the antibacterial efficacy of alexidine and chlorhexidine against Enterococcus faecalis. Methods A total of 50 extracted single-rooted teeth were randomly divided into five groups after being infected with Enterococcus faecalis. The groups were based on irrigants used: Group I - 0.4% alexidine; Group II - 1% alexidine; Group III - 1.5% percent alexidine; Group IV - 2% alexidine; Group V - 2% chlorhexidine. Following irrigation, colony-forming units were determined from the dentinal shavings collected at 400 µm depth. Results Use of 2% alexidine reduced the bacteria effectively when compared to 0.4%, 1%, and 1.5% alexidine. A statistically significant difference was not observed between 2% alexidine and 2% chlorhexidine. Discussion Alexidine, due to its higher virulence factors for bacteria and better bacterial penetrability at 400 µm depth of dentin showed better eradication of Enterococcus faecalis in comparison to chlorhexidine. Conclusion The use of 2% alexidine against Enterococcus faecalis at 400 µm depth of dentin has efficacy comparable to chlorhexidine. Hence, alexidine can be used as an alternative irrigant for chlorhexidine during endodontic procedures.

Antimicrobial effect of nanoparticles in endodontics

Endodontic pathology is most commonly caused by microorganisms. These microorganisms induce irreversible changes in the pulp that can lead to inflammation, necrosis, abscesses, cysts, and other pathological conditions. The treatment for most of these conditions is to remove the pulp, clean and shape the pulp space, followed by obturation. However, the challenges faced in achieving consistent, clinically successful outcomes lies in the total elimination of endodontic pathogens from the root canal system. Despite improved treatment strategies, complete eradication of pathogens is not always a reality. Since, the major challenges in the form of dentinal tubules and microorganisms are all nanoscale, there can be a distinct advantage in using nanoscale materials to tackle these challenges better. Various nanoparticles in the form of silver, chitosan, zinc oxide, etc. have all been tried in endodontics as irrigants, intracanal medicaments, and obturation materials. They have been used as a component of photodynamic disinfection and to modify the materials used for perforation repair and apical seal. These nanoscale products are now available commercially. This chapter will review the applications of antimicrobial nanoparticles in the field of endodontics and their action against specific pathogens.