Search

Background A panel of experts convened by the American Dental Association Council on Scientific Affairs presents an evidence-based clinical practice guideline on nonsurgical treatment of patients with chronic periodontitis by means of scaling and root planing (SRP) with or without adjuncts. Methods The authors developed this clinical practice guideline according to the American Dental Association's evidence-based guideline development methodology. This guideline is founded on a systematic review of the evidence that included 72 research articles providing clinical attachment level data on trials of at least 6 months' duration and published in English through July 2014. The strength of each recommendation ( strong , in favor , weak , expert opinion for , expert opinion against , and against ) is based on an assessment of the level of certainty in the evidence for the treatment's benefit in combination with an assessment of the balance between the magnitude of the benefit and the potential for adverse effects. Practical Implications and Conclusions For patients with chronic periodontitis, SRP showed a moderate benefit, and the benefits were judged to outweigh potential adverse effects. The authors voted in favor of SRP as the initial nonsurgical treatment for chronic periodontitis. Although systemic subantimicrobial-dose doxycycline and systemic antimicrobials showed similar magnitudes of benefits as adjunctive therapies to SRP, they were recommended at different strengths ( in favor for systemic subantimicrobial-dose doxycycline and weak for systemic antimicrobials) because of the higher potential for adverse effects with higher doses of antimicrobials. The strengths of 2 other recommendations are weak : chlorhexidine chips and photodynamic therapy with a diode laser. Recommendations for the other local antimicrobials (doxycycline hyclate gel and minocycline microspheres) were expert opinion for . Recommendations for the nonsurgical use of other lasers as SRP adjuncts were limited to expert opinion against because there was uncertainty regarding their clinical benefits and benefit-to-adverse effects balance. Note that expert opinion for does not imply endorsement but instead signifies that evidence is lacking and the level of certainty in the evidence is low.

Background The authors conducted a systematic review to assess the efficacy and safety of fluoride toothpaste use in children younger than 6 years. Methods The authors defined research questions to formulate a search strategy. They screened studies, extracted data and assessed risk of bias systematically. They conducted meta-analyses to determine the effects of brushing with fluoride toothpaste. Results Use of fluoride toothpaste brushing had a statistically significant effect on mean decayed, missing and filled primary tooth surfaces and decayed, missing and filled primary teeth for populations at high risk of developing caries (standard mean difference [95 percent confidence interval {CI}], −0.25 [−0.36 to −0.14] and −0.19 [−0.32 to −0.06], respectively). The effects of using different fluoride concentration toothpastes on caries varied. Study findings showed either a decrease in the odds of having fluorosis (odds ratio [OR] [95 percent CI] = 0.66 [0.48-0.90]) when the use of fluoride toothpaste was initiated after 24 months or no statistically significant difference (OR [95 percent CI] = 0.92 [0.71-1.18]). Beginning use after 12 or 14 months of age decreased the risk of fluorosis (OR = 0.70 [0.57-0.88]). Conclusions Limited scientific evidence demonstrates that for children younger than 6 years, fluoride toothpaste use is effective in caries control. Ingesting pea-sized amounts or more can lead to mild fluorosis. Practical Implications To minimize the risk of fluorosis in children while maximizing the caries-prevention benefit for all age groups, the appropriate amount of fluoride toothpaste should be used by all children regardless of age. Dentists should counsel caregivers by using oral description, visual aids and actual demonstration to help ensure that the appropriate amount of toothpaste is used.

Background The 2007 American Heart Association (AHA) guidelines for the prevention of infective endocarditis (IE) called for a major reduction in the number of patients recommended for antibiotic prophylaxis (AP) and redefined the dental procedures considered to put these patients at risk of acquiring the infection. The purpose of the authors' study was to determine the acceptance of these changes among and the impact of the changes on dentists and their patients. Methods The authors sent a survey to a random sample of 5,500 dentists in the United States. Results Ninety-five percent of the 878 respondents indicated that they saw patients who receive AP. More than 75 percent were either satisfied or very satisfied with the AHA guidelines, and the respondents indicated that they believed almost three-quarters of their patients also were pleased. Seventy percent of dentists, however, had patients who took antibiotics before a dental procedure even though the guidelines no longer recommend it. Conclusions Acceptance of the 2007 guidelines appears to be high, but controversy remains. Additional scientific data are needed to resolve these issues. Practical Implications The 2007 AHA guidelines have greatly simplified the identification of patients who need AP for dental procedures, given that, in general, far fewer people with cardiac abnormalities are considered to be at risk as a result of invasive procedures. Some physicians, however, continue to prescribe antibiotics for some patients whom the AHA no longer considers to need them. Patients also may choose to continue this practice themselves. There is ongoing controversy surrounding this common clinical question in dental practice, and the next guidelines from the AHA may change on the basis of data from future clinical studies.

Background The authors conducted a systematic review on this research question: "In populations where nondentists conduct diagnostic, treatment planning, and/or irreversible/surgical dental procedures, is there a change in disease increment, untreated dental disease, and/or cost-effectiveness of dental care?" Methods The authors searched 12 electronic databases for articles published through February 2012 and hand searched relevant articles. They assessed the risk of bias of included studies and extracted data. Results The authors screened 7,701 citations, resulting in 18 observational studies that met the inclusion criteria. They judged 13 of the studies to be at high risk of bias, five at moderate risk and one at low risk. The authors found no data regarding cost effectiveness, irreversible diagnostic procedures or diseases other than caries. Conclusions The authors concluded that the quality of the evidence was poor. They found that in select groups in which participants received irreversible dental treatment from teams that included midlevel providers, caries increment, caries severity or both decreased across time; however, there was no difference in caries increment, caries severity or both compared with those in populations in which dentists provided all irreversible treatment. In select groups in which participants had received irreversible dental treatment from teams that included midlevel providers, there was a decrease in untreated caries across time and a decrease in untreated caries compared with that in populations in which dentists provided all treatment. Clinical Implications Generalizability of results to populations other than those studied is limited owing to the age of some of the studies, as well as to clinical and methodological heterogeneity; consequently, the conclusions should be viewed with caution.

The Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures evidence-based clinical practice guideline was codeveloped by the American Academy of Orthopaedic Surgeons (AAOS) and the American Dental Association. This guideline replaces the previous AAOS Information Statement, “Antibiotic Prophylaxis in Bacteremia in Patients With Joint Replacement,” published in 2009. Based on the best current evidence and a systematic review of published studies, three recommendations have been created to guide clinical practice in the prevention of orthopaedic implant infections in patients undergoing dental procedures. The first recommendation is graded as Limited; this recommendation proposes that the practitioner consider changing the long-standing practice of routinely prescribing prophylactic antibiotic for patients with orthopaedic implants who undergo dental procedures. The second, graded as Inconclusive, addresses the use of oral topical antimicrobials in the prevention of periprosthetic joint infections. The third recommendation, a Consensus statement, addresses the maintenance of good oral hygiene.

Gut-associated lymphoid tissue (GALT) development requires interaction with the intestinal microbiota. Because murine secondary lymphoid tissue development is driven by positive feedback interactions between B cells and stromal cells, we used in situ hybridization to determine whether intestinal commensals influence such interactions during rabbit appendix development. The features of positive feedback interactions we examined (CXCL13 mRNA expression, B cell accumulation and FDC differentiation) increased during early follicle development, but stalled in the absence of intestinal commensals. These features were reinitiated by commensals that stimulated follicle development and intrafollicular B cell proliferation. Our results suggest that rabbit appendix follicles develop in two phases: an initial phase of B cell recruitment to nascent follicles, possibly through positive feedback interactions, and a subsequent phase of intrafollicular B cell proliferation stimulated by intestinal commensals. In addition, we found that intestinal commensals stimulate appendix CCL21 mRNA expression and T cell area formation.

Background Conduct a systematic review and meta-analysis on nonsurgical treatment of patients with chronic periodontitis by means of scaling and root planing (SRP) with or without adjuncts. Methods A panel of experts convened by the American Dental Association Council on Scientific Affairs conducted a search of PubMed (MEDLINE) and Embase for randomized controlled trials of SRP with or without the use of adjuncts with clinical attachment level (CAL) outcomes in trials at least 6 months in duration and published in English through July 2014. The authors assessed individual study bias by using the Cochrane Risk of Bias Tool and conducted meta-analyses to obtain the summary effect estimates and their precision and to assess heterogeneity. The authors used funnel plots and Egger tests to assess publication bias when there were more than 10 studies. The authors used a modified version of the US Preventive Services Task Force methods to assess the overall level of certainty in the evidence. Results The panel included 72 articles on the effectiveness of SRP with or without the following: systemic antimicrobials, a systemic host modulator (subantimicrobial-dose doxycycline), locally delivered antimicrobials (chlorhexidine chips, doxycycline hyclate gel, and minocycline microspheres), and a variety of nonsurgical lasers (photodynamic therapy with a diode laser, a diode laser, neodymium:yttrium-aluminum-garnet lasers, and erbium lasers). Conclusions and Practical Implications With a moderate level of certainty, the panel found approximately a 0.5-millimeter average improvement in CAL with SRP. Combinations of SRP with assorted adjuncts resulted in a range of average CAL improvements between 0.2 and 0.6 mm over SRP alone. The panel judged the following 4 adjunctive therapies as beneficial with a moderate level of certainty: systemic subantimicrobial-dose doxycycline, systemic antimicrobials, chlorhexidine chips, and photodynamic therapy with a diode laser. There was a low level of certainty in the benefits of the other included adjunctive therapies. The panel provides clinical recommendations in the associated clinical practice guideline.

The rabbit appendix is organized structurally into multiple B cell follicles separated, at their sub-apical regions, by well-defined T cell areas. We found, by RNA in situ hybridization, that the B cell chemoattractant CXCL13 (B-lymphocyte chemoattractant, or BLC) is highly expressed in the B cell follicles. In addition, we found that the T cell chemoattractant CCL21 (secondary lymphoid tissue chemokine, or SLC) is highly expressed in the T cell areas. The localized expression of these chemoattractants likely organizes the B and T cell areas of the appendix. Surprisingly, however, we found that the localized expression of CXCL13 and CCL21 differs dramatically in early neonatal appendix. At two days after birth, CXCL13 expression was confined to the appendix domes and CCL21 expression was localized in a continuous layer significantly beneath the domes. Over subsequent days, as B cells accumulated in the domes and began proliferating, developing follicles gradually distended downward through the layer of CCL21 expression, ultimately generating the characteristic organization of B and T cell areas seen in the adult appendix. This developmental process might be important in establishing an environment supportive of B cell proliferation and antibody repertoire diversification, which occur in the rabbit appendix between 3 and 6 weeks of age.