The malignant transformation of oral lichen planus and oral lichenoid lesions: A systematic review

BackgroundDetermining the potential for malignant transformation of oral lichen planus (OLP) is complicated by difficulties in diagnosis, differentiation from oral lichenoid lesions (OLLs) and the phenomenon of premalignant lesions' exhibiting lichenoid characteristics. The authors of this systematic review evaluated evidence regarding malignant transformation of OLP and characterized transformation prevalence, clinical characteristics of OLP lesions developing into squamous cell carcinoma (SCC) and time to transformation.Types of Studies ReviewedThe authors searched PubMed, Embase and Thomson Reuters Web of Science in a systematic approach. They evaluated observational English-language studies involving human participants published in peer-reviewed journals. Inclusion required patients to have the diagnosis of OLP or OLL as confirmed with biopsy results on initial enrollment. They excluded all patients who had dysplasia on initial biopsy of OLP or OLL lesions.ResultsSixteen studies were eligible. Among 7,806 patients with OLP, 85 developed SCC. Among 125 patients with OLL, four developed SCC. The rate of transformation in individual studies ranged from 0 to 3.5 percent. The overall rate of transformation was 1.09 percent for OLP; in the solitary study in which investigators evaluated OLL, the rate of transformation was 3.2 percent. Patients' average age at onset of SCC was 60.8 years. The authors noted a slight predominance of female patients among those who experienced malignant transformation. The most common subsite of malignant transformation was the tongue. The average time from diagnosis of OLP or OLL to transformation was 51.4 months.Practical ImplicationsA small subset of patients with a diagnosis of OLP eventually developed SCC. The most common demographic characteristics of patients in this subset were similar to the most common demographic characteristics associated with OLP in general (that is, being female, being older and being affected in areas common to this condition). It is prudent for clinicians to pursue continued regular observation and follow-up in patients with these conditions, even in patients who do not fit a traditional high-risk category for oral SCC.     

Concordance between clinical practice and published evidence: Findings from The National Dental Practice-Based Research Network

BackgroundDocumenting the gap between what is occurring in clinical practice and what published research findings suggest should be happening is an important step toward improving care. The authors conducted a study to quantify the concordance between clinical practice and published evidence across preventive, diagnostic and treatment procedures among a sample of dentists in The National Dental Practice-Based Research Network (“the network”).MethodsNetwork dentists completed one questionnaire about their demographic characteristics and another about how they treat patients across 12 scenarios/clinical practice behaviors. The authors coded responses to each scenario/clinical practice behavior as consistent (“1”) or inconsistent (“0”) with published evidence, summed the coded responses and divided the sum by the number of total responses to create an overall concordance score. The overall concordance score was calculated as the mean percentage of responses that were consistent with published evidence.ResultsThe authors limited analyses to participants in the United States (N = 591). The study results show a mean concordance at the practitioner level of 62 percent (SD = 18 percent); procedure-specific concordance ranged from 8 to 100 percent. Affiliation with a large group practice, being a female practitioner and having received a dental degree before 1990 were independently associated with high concordance (≥ 75 percent).ConclusionDentists reported a medium-range concordance between practice and published evidence.Practical ImplicationsEfforts to bring research findings into routine practice are needed.     

The accuracy of diagnostic tests for adenoid hypertrophy: A systematic review

BackgroundAdenoid hypertrophy may cause sleep-disordered breathing and altered craniofacial growth. The authors conducted a study to gauge the accuracy of alternative tests compared with nasoendoscopy (reference standard) for screening adenoid hypertrophy.MethodsThe authors conducted a systematic review that included searches of electronic databases, hand searches of bibliographies of relevant articles and gray literature searches. They included all articles in which an alternative test was compared with nasoendoscopy in children with suspected nasal or nasopharyngeal airway obstruction.ResultsThe authors identified seven articles that were of poor to good quality. They identified the following alternative tests: multirow detector computed tomography (sensitivity, 92 percent; specificity, 97 percent), videofluoroscopy (sensitivity, 100 percent; specificity, 90 percent), rhinomanometry with decongestant (sensitivity, 83 percent; specificity, 83 percent) and clinical examination (sensitivity, 22 percent; specificity, 88 percent). Lateral cephalograms tended to have good to fair sensitivity (typically 61-75 percent) and poor specificity (41-55 percent) when adenoid size was evaluated but excellent to good specificity when airway patency was evaluated (68-96 percent).ConclusionsNo ideal tool exists for dentists to screen adenoid hypertrophy, owing to access constraints, radiation concerns and suboptimal diagnostic accuracy. Research is needed to identify a low-risk, easily acceptable, highly valid diagnostic screening tool.Practical ImplicationsAlthough lateral cephalograms (which have good to fair sensitivity) and a thorough medical history (which has good specificity) are imperfect individually, when they are used together, they can compensate for each other's weaknesses. This combined approach is the best tool available to dentists for screening adenoid hypertrophy.     

Assessing the association between bisphosphonate exposure and delayed mucosal healing after tooth extraction

BackgroundTooth extraction in patients exposed to bisphosphonates (BPs) is considered a risk factor for osteonecrosis. The authors evaluated the time to mucosal healing and frequency of osteonecrosis after tooth extraction in participants exposed to BPs.MethodsThe authors compared wound healing after tooth extraction in participants exposed to BPs with that in control participants who had not been exposed to BPs. Variables included age, sex, type of BP therapy (oral or intravenous), BP exposure time and C-terminal telopeptide (CTX) test results. The authors followed up patients weekly or biweekly until healing was complete. They used multivariable analyses to model time to healing in the presence of covariates, and estimates provided hazard ratios (HRs) and 95 percent confidence intervals (CIs) adjusted for all variables in the model.ResultsThe authors enrolled 53 participants with BP exposure and 39 control participants. Postextraction healing was significantly longer in participants exposed to BPs (P < .001) than it was in control participants. One patient (1.9 percent) developed osteonecrosis. A Cox proportional hazards model in which the authors controlled for age, sex and CTX values showed that BP exposure alone significantly (adjusted HR, 0.27; 95 percent confidence interval, 0.16–0.48) increased mucosal healing time.ConclusionsThe study results showed that postextraction healing was impaired in patients exposed to BPs. CTX values were not associated with delayed healing after tooth extraction.Practical ImplicationsPostextraction healing was delayed in patients receiving BP therapy. However, the risk of developing osteonecrosis was low.     

Diagnostic capability of questionnaires and clinical examinations to assess sleep-disordered breathing in children: A systematic review and meta-analysis

BackgroundThe reference standard for the diagnosis of pediatric sleep-disorder breathing (SDB) is a full polysomnography (PSG) (an overnight sleep study). There are many obstacles to children being able to undergo a full PSG; therefore, the authors evaluated the diagnostic value of alternative diagnostic methods (clinical history and physical examination) for pediatric SDB.Types of Studies ReviewedThe authors selected articles in which the investigators' primary objective was to evaluate the diagnostic capability of physical evaluations and questionnaires compared with the current reference standard (that is, a full PSG) to diagnose SDB in children younger than 18 years. The authors searched several electronic databases without limitations.ResultsUsing a two-step selection process, the authors identified 24 articles and used them to conduct a qualitative analysis. They conducted a meta-analysis on 11 of these articles. Among these articles, only one involved a test that had diagnostic accuracy good enough to warrant its use as a screening method for pediatric SDB, but its diagnostic accuracy was not sufficient to be considered a true diagnostic tool (that is, a replacement for full PSG) for pediatric SDB.Practical ImplicationsThe involvement of dentists in the screening process for pediatric SDB can contribute significantly to children's health. The identified questionnaire could be considered an acceptable screening test to determine which children to refer to a sleep medicine specialist.     

Risk of adrenal crisis in dental patients: Results of a systematic search of the literature

BackgroundThe authors performed a systematic search of the literature to identify the frequency of, risk of experiencing and factors associated with adrenal crises in dental patients.MethodsThe authors searched PubMed and Ovid MEDLINE (1947-June 20, 2012) and Embase (1974-2012) for English-language articles related to cases of adrenal crisis in dentistry and extracted and analyzed data from the articles. The six authors determined whether the cases identified met a consensus definition of adrenal crisis.ResultsOf 148 articles identified in the initial screening, 34 articles were included in the final review, from which six cases met the criteria of adrenal crisis. The authors categorized four cases as “suggestive of adrenal crisis” and two cases as “consistent with adrenal crisis.” Risk factors were significant adrenal insufficiency, pain, infection, having undergone an invasive procedure, having received a barbiturate general anesthetic, and poor health status and stability at the time of presentation. The authors estimated risk to be less than one in 650,000 in patients with adrenal insufficiency.ConclusionsAdrenal crisis is rare in dental patients, with only six reports of it having been published in the past 66 years. Risk is associated with unrecognized adrenal insufficiency, poor health status and stability at the time of treatment, pain, infection, having undergone an invasive procedure and having received a barbiturate general anesthetic.Clinical ImplicationsRisk of adrenal crisis is reduced through proper evaluation of the patient, identification of risk factors and following appropriate preventive measures.     

The frequency and nature of incidental findings in cone-beam computed tomographic scans of the head and neck region: A systematic review

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The authors analyzed the literature critically to determine the frequency and nature of incidental findings (IFs) in cone-beam computed tomographic (CBCT) scans of the head and neck region.Types of Studies ReviewedThe authors conducted a systematic search of several electronic databases (MEDLINE, Embase, PubMed, Scopus, Web of Science, the Cochrane Library) through July 14, 2012, as well as a limited gray-literature search (in Google Scholar). Inclusion criteria encompassed the frequency of reports of IFs in the head and neck region in CBCT imaging, regardless of the sample origin. The authors used no search limitations. They evaluated methodological quality according to 15 criteria related to study design, population characteristics and statistical analysis.ResultsInitially, the authors identified 66 articles from the electronic database searches and another one via the gray-literature search. Once they applied the final selection criteria, they found that only five articles satisfied the inclusion criteria. In articles in which investigators reported the number of IFs as the absolute number of IFs detected, the frequency ranged from 1.3 to 2.9 IFs per CBCT scan. Conversely, in articles in which authors reported the number of IFs as the number of scans containing IFs, the frequency ranged from 24.6 to 93.4 percent of CBCT scans. Methodological quality averaged 77.2 percent (range, 60-93 percent) of the maximum possible score.Conclusions and Clinical ImplicationsIFs are detected relatively frequently in CBCT imaging, and considerable variation is evident in their frequency and nature. The majority are extragnathic findings (that is, those found outside the region of the dentition and alveolus), thus emphasizing the need for complete and proper review of the entire image, regardless of field of view or region of interest.     

Tooth preservation or implant placement: A systematic review of long-term tooth and implant survival rates

BackgroundFor the past few decades, dental implants have served as reliable replacements for missing teeth. However, there is an increasing trend toward replacing diseased teeth with dental implants.Types of Studies ReviewedThe authors conducted a systematic review of long-term survival rates of teeth and implants. They searched the MEDLINE database for relevant publications up to March 2013. They considered studies in which investigators assessed the long-term effectiveness of dental implants or that of tooth preservation. They included only studies that had follow-up periods of 15 years or longer.ResultsThe authors selected 19 articles for inclusion. Investigators in nine studies assessed the tooth survival rate, whereas investigators in 10 studies assessed the implant survival rate. When comparing the overall long-term (that is, 15 years or more) tooth loss rate with that of implants, the authors observed rates ranging between 3.6 and 13.4 percent and 0 and 33 percent for teeth and implants, respectively. They could not perform a meta-analysis because of the substantial differences between the studies.Practical ImplicationsThe results of this systematic review show that implant survival rates do not exceed those of compromised but adequately treated and maintained teeth, supporting the notion that the decision to extract a tooth and place a dental implant should be made cautiously. Even when a tooth seems to be compromised and requires treatment to be maintained, implant treatment also might require additional surgical procedures that might pose some risks as well. Furthermore, a tooth can be extracted and replaced at any time; however, extraction is a definitive and irreversible treatment.     

The influence of hemostatic agents on dentin and enamel surfaces and dental bonding: A systematic review

Background.Hemostatic agents have been used clinically in dentistry for many years to control bleeding. The authors reviewed scientific publications in which researchers investigated the effects of hemostatic agents on dentin and enamel surfaces and on bonding of adhesive systems and resin cements.Types of Studies Reviewed.The authors screened PubMed and Scopus databases for studies in English published from 1980 to 2013. They read the titles and abstracts to identify literature that fulfilled the inclusion criteria. The authors included studies in which researchers evaluated the hemostatic action on the dentin and enamel surfaces or its influence on the bond strength of adhesive systems or resin cements. They used cross-referencing to identify more articles.Results.Twenty in vitro studies met the inclusion criteria. Investigators in 12 of these studies evaluated the bond strength to contaminated dentin. Investigators in 10 of these studies reported a significant decrease in bond strength. Those in two studies evaluated the influence of a hemostatic agent on the dental enamel and reported decreases in bond strength. Researchers also reported significant increases in microleakage of self-etching adhesives on contaminated dentin. Scanning electron microscopy revealed partial removal of the smear layer or an etching effect of dentin as a result of the application of hemostatic agents on dentin.Practical Implications.Adhesive procedures may be affected adversely when performed on dentin and enamel contaminated by hemostatic agents. Hemostatic agents may induce changes in the dentin surface morphology. The results of this review indicate that the bond strength of self-etching adhesive systems is affected more negatively than is that of etch-and-rinse systems. The authors found that a 60-second application of ethylenediaminetetraacetic acid followed by a water spray restored the bond strength of a self-etching adhesive to dentin; use of phosphoric acid for 15 seconds followed by a water spray also was an effective cleaning method. Direct comparison of selected studies was not possible, however, mainly because of methodological differences hampering definitive conclusions.     

Effectiveness of a resin-modified glass ionomer liner in reducing hypersensitivity in posterior restorations: A study from the Practitioners Engaged in Applied Research and Learning Network

BackgroundThe objectives of this randomized comparative effectiveness study conducted by members of the Practitioners Engaged in Applied Research and Learning (PEARL) Network were to determine whether using a resin-modified glass ionomer (RMGI) liner reduces postoperative hypersensitivity (POH) in dentin-bonded Class I and Class II resin-based composite (RBC) restorations, as well as to identify other factors (putative risk factors) associated with increased POH.MethodsPEARL Network practitioner-investigators (P-Is) (n = 28) were trained to assess sensitivity determination, enamel and dentin caries activity rankings, evaluation for sleep bruxism, and materials and techniques used. The P-Is enrolled 341 participants who had hypersensitive posterior lesions. Participants were randomly assigned to receive an RBC restoration with or without an RMGI liner before P-Is applied a one-step, self-etching bonding agent. P-Is conducted sensitivity evaluations at baseline, at one and four weeks after treatment, and at all visits according to patient-reported outcomes.ResultsP-Is collected complete data regarding 347 restorations (339 participants) at baseline, with 341 (98 percent) (333 participants) recalled at four weeks. Treatment groups were balanced across baseline characteristics and measures. RBC restorations with or without an RMGI liner had the same one-week and four-week POH outcomes, as measured clinically (by means of cold or air stimulation) and according to patient-reported outcomes.ConclusionsUse of an RMGI liner did not reduce clinically measured or patient-reported POH in moderate-depth Class I and Class II restorations. Cold and air clinical stimulation findings were similar between groups.Practical Implications. The time, effort and expense involved in placing an RMGI liner in these moderate-depth RBC restorations may be unnecessary, as the representative liner used did not improve hypersensitivity outcomes.     

At-home oral care for adults with developmental disabilities: A survey of caregivers

BackgroundLittle is known about effective at-home oral care methods for people with developmental disabilities (DDs) who are unable to perform personal preventive practices themselves and rely on caregivers for assistance.MethodsA convenience sample of 808 caregivers (84.5 percent paid, 15.5 percent family members) who accompanied adults with DDs (20 years or older) to appointments at a specialized statewide dental care system completed computer-assisted personal interview surveys. The authors used these data to investigate caregivers' at-home oral care experiences and to explore differences between caregivers who were paid and those who were family members.ResultsCaregivers reported that a high proportion (85 percent) of dentate adults with DDs received assistance with tooth cleaning. They also reported a high prevalence of dental problems, and low adherence to brushing (79 percent) and flossing (22 percent) recommendations. More caregivers reported that they felt confident assisting with brushing than with flossing (85 percent versus 54 percent). Family members and paid caregivers differed with respect to confidence and training.ConclusionsAt-home oral care, particularly flossing, presents substantial challenges for adults with DDs. Solutions must be tailored to address the different experiences and distinct needs of the family members and paid caregivers who assist these adults.Practical ImplicationsCaregivers play an important role in providing at-home oral care, and they must be included in efforts to improve oral health outcomes for people with DDs.     

Positive association between conflicts of interest and reporting of positive results in randomized clinical trials in dentistry

BackgroundThe relationship between industry funding and study results has been explored widely in medicine but not in dentistry. The authors aimed to assess the relationship between conflicts of interest (COIs) and study results.MethodsThe authors assessed all randomized clinical trials (RCTs) published between July 2010 and June 2012 in the 10 dental journals with the highest impact factors in dentistry. The authors used three definitions of COI and explored their associations with positive study results.ResultsDepending on the definition of COI, the odds ratio for reporting positive results varied between 2.40 (95 percent confidence interval CI, 1.16–5.13) and 9.19 (95 percent CI, 1.71–170.64). The authors found no association between positive study results and journal of publication or area of practice.ConclusionsRCTs in which authors have some type of COI are more likely to have results that support the intervention being assessed.Practical ImplicationsWhen reviewing the results of RCTs, clinicians need to be aware of the association between reporting positive study results and the type of COI disclosure and be even more careful when critically appraising and applying their results.     

The impact of oral disease and nonsurgical treatment on bacteremia in children

BACKGROUND: The authors examine the role of dental disease and nonsurgical dental procedures in the incidence and duration of bacteremia in children. METHODS: The authors randomized a group of children to receive amoxicillin or a placebo before dental rehabilitation in an operating room setting. They collected eight blood draws at the following times: two minutes after intubation (draw 1); after dental restorations, pulp therapy and cleaning (draw 2); 10 minutes later (draw 3); and five draws during and after dental extractions (draws 4-8). The authors compared dental disease parameters and the type of dental procedures performed with the incidence and duration of bacteremia. RESULTS: The authors enrolled 100 children (aged 1-8 years) in the study. The incidence of bacteremia from draw 2 was 20 percent in the placebo group and 6 percent in the amoxicillin group (P = .07), and the incidence from draw 3 was 16 percent in the placebo group and zero percent in the amoxicillin group (P = .03). Subjects with higher gingival scores were more likely to have a bacteremia for draw 2 (P = .01). The authors found that subjects in the group with bacteremia for draw 3 had undergone more pulpotomies than did subjects in the group without bacteremia for draw 3 (3 +/- 2.5 standard deviation [SD] versus 1.5 +/- 1.6 SD, P = .04), while they found almost no differences for draw 2. CONCLUSIONS: This study suggests that gingival disease has an impact on bacteremia after dental restorations and prophylaxis. Although antibiotics have an impact, they do not eliminate bacteremia altogether.     

The role of dentin moisture in the degradation of resin-dentin interfaces under clinical and laboratory conditions

BackgroundThe authors conducted a study to evaluate the influence of dentin moisture on the degradation of the resin-dentin interface in primary teeth under clinical and laboratory conditions.MethodsThe authors prepared 40 Class I restorations (five teeth per group) by using a cylindrical diamond bur, leaving a flat dentin surface on the pulpal floor. They vigorously rubbed two coats of a simplified etch-and-rinse adhesive on either dry or wet demineralized dentin under clinical or laboratory conditions. After performing restorative procedures, the authors extracted teeth prepared under clinical conditions after 20 minutes (immediately) or the teeth exfoliated after six months. The authors also tested the teeth prepared under laboratory conditions immediately or after six months of being stored in water. They sectioned the teeth to obtain resin-dentin bonded specimens for microtensile testing and for silver nitrate uptake (SNU) under scanning electron microscopy. They performed a three-way analysis of variance and Tukey test (α = .05) on the SNU bond strength data.ResultsStatistically higher bond strength values (megapascals [standard deviation]) were observed when bonding was performed under laboratory conditions (clinical = 25.2 [3.6] MPa versus laboratory = 28.5 [4.4] MPa; P < .05). Degradation occurred only in the wet dentin groups under both experimental conditions (immediately = 31.3 [4.5] MPa versus after six months = 21.3 [2.1] MPa; P < .05). SNU occurred in all groups and was statistically higher after six months of clinical function or water storage (immediately = 13.9 [4.9 SD] percent versus after six months = 34.1 [4.5 SD] percent; P < .05).ConclusionsThe bonding of adhesives to dry demineralized dentin produces adhesive interfaces that are more resistant to degradation regardless of the bonding condition.Clinical ImplicationsResin-dentin bond strengths produced under laboratory conditions in primary teeth may be higher than those obtained under clinical circumstances, although both conditions (clinical and laboratory) seemed to yield similar results. Bonding to dry demineralized primary tooth dentin produced resin-dentin interfaces that were more resistant to degradation.