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Efficacy and Safety of Pulpal Anesthesia Strategies during Endodontic Treatment of Permanent Mandibular Molars with Symptomatic Irreversible Pulpitis: A Systematic Review and Network Meta-analysis

Published online: October 07, 2019

Abstract

Introduction

Several strategies have been investigated for achieving successful pulpal anesthesia during endodontic treatment of mandibular molars with symptomatic irreversible pulpitis. However, comprehensive evaluation and identification of the most efficacious and safe intervention are lacking. We aimed to determine this using network meta-analysis.

Methods

MEDLINE, Embase, Cochrane Central, CINAHL, and Scopus databases were searched. Study selection and data extraction were performed in duplicate. Eligible randomized controlled trials were meta-analyzed to estimate the treatment effects (odd ratios [ORs]; 95% credible interval (CrI) and surface under the cumulative ranking curve (SUCRA)]. CINeMA software (University of Bern, Bern, Switzerland) was used to assess the quality of results.

Results

Thirty-seven interventions from 46 studies were identified. Compared with the common practice of an inferior alveolar nerve block with 2% lidocaine, a supplemental intraosseous injection was ranked the most efficacious with very low to moderate confidence (2% lidocaine + preoperative nonsteroidal anti-inflammatory drugs [NSAIDs] + acetaminophen [OR = 74; 95% CrI, 15–470; SUCRA = 97%], 2% lidocaine + preoperative NSAIDs [OR = 46; 95% CrI, 8–420; SUCRA = 94%], 2% lidocaine [OR = 33; 95% CrI, 14–80; SUCRA = 93%], 2% lidocaine + preoperative opioids + acetaminophen [OR = 20; 95% CrI, 4.4–98; SUCRA = 86%], and 4% articaine [OR = 20; 95% CrI, 6.3–96; SUCRA = 87%]) followed by supplemental buccal and lingual infiltrations using 4% articaine + preoperative NSAIDs (OR = 18; 95% CrI, 6–56; SUCRA = 86%; very low confidence). No major safety concerns were reported.

Conclusions

Very low- to moderate-quality evidence suggests intraosseous injection using 2% lidocaine with 1:100,000 epinephrine or 4% articaine with 1:100,000 epinephrine or buccal and lingual infiltrations of 4% articaine with 1:100,000 epinephrine are superior strategies to achieve pulpal anesthesia during endodontic treatment of mandibular molars with symptomatic irreversible pulpitis. Preoperative NSAIDs or opioids with or without acetaminophen may increase the efficacy of these injections.
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New Mid-Class Prosthetic Teeth Line Delivers Unprecedented Blend of Aesthetics, Easy Handling , Versatility and Value


Kulzer’s Delara universal tooth line represents a new go-to option for labs
South Bend, IN/10.08.2019. Kulzer, a global leader in dental materials, has announced the launch of its Delara tooth line, which sets a new standard for mid-priced prosthetic teeth by delivering modern layering, natural aesthetics, and easy handling. Like Kulzer’s Mondial, Mondial i, Artic and Basic prosthetic tooth lines, and in keeping with the company’s long-standing tradition of in-depth cooperation with dental professionals, the Delara line was developed by dental technicians for dental technicians.
Coming to market in the fourth quarter of 2019, Delara features 16 VITA shades and 2 bleach shades (BL2 and BL3) in an optimized portfolio to meet universal needs. Its unique surface structure allows for natural light shattering and provides modern shading, as opposed to the dull appearance of some prosthetic tooth lines. Due to its easy processing characteristics, even dental technicians who make corrections can rest assured that Delara’s aesthetics and lifelike effect will not be lost. The teeth provide for lively transparency and successfully manage to avoid the undesirable gray or yellowish effect that can occur in the mouth with other products.
One tooth line that meets virtually every need
In addition to being visually impressive, Delara teeth offer a natural feel and excellent functionality. Technicians will appreciate the easy processing, while lab owners will appreciate great versatility and value. Dental labs that use it as their go-to line of prosthetic teeth will find that they are able to complete the majority of their restoration work more efficiently – with less need for grinding to adjust the shape – while still delivering quality restorations.
© 2019 Kulzer, LLC. All Rights Reserved.
A wealth of benefits
Dental laboratories will appreciate Delara’s many benefits, including:

  • Beautiful, lifelike aesthetics: Modern, bright shading, dynamic light refraction from the vivid surface structure and anatomical forms give Delara a vibrant and fresh appearance.
  • Easy handling for enhanced productivity: Simple setup with a polishing buffer, a basal grinding reserve, optimized incisal edges and reduced cusps for easy interlock create added efficiency and predictability for busy labs.
    Versatility: Various setup possibilities (from tooth-to-tooth to cross bite), CAD/ CAM production for easy integration into digital workflows, and great functionality mean Delara delivers as a universal, go-to line of prosthetic teeth.

Excellent value: A great price-to-performance ratio that sets a new standard for prosthetics in the mid-priced segment – all with Kulzer quality and the excellent durability and comfort that patients can enjoy for a lifetime.
Due to its easy processing characteristics, even dental technicians who make corrections can rest assured that Delara’s aesthetics and lifelike effect will not be lost,” said Obie Clifford , Kulzer Product Manager. “The teeth provide for lively transparency and successfully manage to avoid the undesirable gray or yellowish effect that can occur in the mouth with other products.”
A rich history of prosthetic tooth innovation
A manufacturer of dental acrylics since the 1930s, Kulzer has developed a tradition of quality, reliability, excellent aesthetics and innovation unmatched within the field of dental prosthetics. The company is particularly renowned for its expertise in balancing optimal functionality with the highest aesthetics.
Kulzer prides itself on listening closely and regularly to its customers in order to ensure that its products perform exactly as dental technicians, dentists and their patients expect. To that end, the company develops all of its denture products, including its new Delara line, in close collaboration with internal and external dental technicians.

© 2019 Kulzer, LLC. All Rights Reserved.
For more information about Kulzer and its other award-winning products and services, please visit www.kulzerUS.com.
Kulzer North America
Kulzer North America is a South Bend, Indiana-based division of Kulzer GmbH. As one of the world’s leading dental companies, Kulzer has been a reliable partner for all dental professionals for more than 80 years. Whether aesthetic or digital dentistry, tooth preservation, prosthetics or periodontology, Kulzer stands for trusted and innovative dental products. With optimal solutions and services, Kulzer aims to support its customers in restoring their patients’ oral health in a safe, simple and efficient way. For this purpose, 1500 employees work in 26 locations in the fields of research, manufacturing and marketing.
Kulzer is part of the Mitsui Chemicals Group. The Japanese Mitsui Chemicals Inc. (MCI) based in Tokyo owns 131 affiliates with more than 17,200 employees in 27 countries. Its innovative and functional chemical products are as much in demand in the automotive, electronics and packaging industries as in environmental protection and healthcare.
Up to July 2017, Kulzer operated under the name of Heraeus Kulzer. By changing the name, Kulzer will focus on its strengths that have made it successful: loyal partnerships with users, distributors and universities, and, above all, highest quality materials, innovations and a spectrum of services that is unique in the market.
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A randomized, prospective clinical study evaluating effectiveness of a bulk-fill composite resin, a conventional composite resin and a reinforced glass ionomer in Class II cavities: one-year results

Journal of Applied Oral Science

\J. Appl. Oral Sci. vol.27  Bauru  2019  Epub Oct 07, 2019

http://dx.doi.org/10.1590/1678-7757-2018-0678 

Original Article
A randomized, prospective clinical study evaluating effectiveness of a bulk-fill composite resin, a conventional composite resin and a reinforced glass ionomer in Class II cavities: one-year results

Bulk-fill restorative materials such as bulk-fill composite resins and high viscous glass ionomer cements have become very popular materials in operative dentistry because their application is easy and time-saving.

Objectives:

The aim of this clinical study was to evaluate the clinical performance of a highly viscous reinforced glass ionomer material, a bulk-fill composite resin and a micro hybrid composite resin in Class II restorations.

Methodology:

In total, 109 Class II restorations were performed in 54 patients using three different restorative materials: Charisma Smart Composite (CSC); Filtek Bulk Fill Posterior Restorative (FBF); Equia Forte Fil (EF). Single Bond Universal adhesive (3M ESPE, Germany) was used with composite resin restorations. The restorations were evaluated using modified USPHS criteria in terms of retention, color match, marginal discoloration, anatomic form, contact point, marginal adaptation, secondary caries, postoperative sensitivity and surface texture. The data were analyzed using Chi-Square, Fischer’s and McNemar’s tests.

Results:

At the end of one year, 103 restorations were followed up. No changes were observed during the first 6 months. At the end of one year, there were small changes in composite restorations (FBF and CSC) but no statistically significant difference was observed between the clinical performances of these materials for all criteria (p>0.05). However, there was a statistically significant difference between EF, FBF and CSC groups in all parameters except marginal discoloration, secondary caries and postoperative sensitivity in one-year evaluation (p<0 .05="" p="">

Conclusion:

Bulk-fill composite resins and conventional composite resins showed more successful clinical performance than highly viscous reinforced glass ionomers in Class II cavities.

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ACCURACY OF DETECTING CARIES BENEATH COMPOSITE RESIN RESTORATIONS USING THE CANARY SYSTEM, BITEWING RADIOGRAPHS AND CONEBEAM CT SCAN


A new paper was just published in Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology that evaluated the accuracy of The Canary System, Bitewing Radiographs and Cone Beam CT for detecting natural caries under composite restorations in interproximal regions (https://doi.org/10.1016/j.oooo.2019.09.006).  This study found that The Canary System was more accurate than Bitewing Radiographs and Cone Beam CT in detecting caries on the gingival floor beneath composite restorations.  The sensitivity and specificity data (table on the right) indicates that The Canary System could find 89% of the caries where the other devices found 40% of the lesions.
One of the major reasons for replacing restorations is tooth decay that develops around the edges of the filling.  This study found that “Radiographs though valuable in the detection of advanced caries lesions, are less sensitive for early or recurrent lesions under restorations.”  The Canary System which does not use ionizing radiation can serve as a sensitive tool in early caries detection.
The findings in this study mirror the findings from other studies done by Dr. Amaechi’s group at the University of Texas at San Antonio.  A clinical trial, which was reported at a research conference in 2015, found The Canary System was superior to bitewing radiography for the detection of proximal caries.  The Canary System found 92% of the caries while bitewing radiographs found only 67%.
Radiographs including bitewings are commonly used to detect caries at the interproximal or contact areas but they do not reveal enamel white-spot lesions or all recurrent caries around restorations.  Approximately 30%–40% mineral loss is necessary before an early enamel caries lesion is visible radiographically and demineralization may not appear radiographically until at least 9 months or longer after initiation.
Finding decay early may allow oral health providers to use various preventive / remineralization products to help stabilize the lesion or re-harden it. 
The Canary System, with its unique crystal structure diagnostics, can quantify, image, monitor and record changes in the structure of enamel, dentin and cementum. It can detect caries beneath opaque sealants, around the margins of restorations, around orthodontic brackets and beneath interproximal, occlusal and smooth surfaces.
Visit www.thecanarysystem.com or email sales@thecanarysystem.com to request additional informatio
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Improved Root Canal Instrumentation to Reduce Dental Work Complications

Doctors suggest that the "adaptive" motion of nickel-titanium rotary files used for root canal procedures decreases the instrument’s torque generation, thereby reducing the risk of tooth damage and file fracture

YANGSAN, South Korea, Oct. 7, 2019 /PRNewswire/ — Reducing dental work complications is in best interest of dentists as well as patients. To improve clinical performance of root canal instruments, a research team, led by Dr. Sang Won Kwak from Pusan National University, South Korea, tested instrumentation with specially designed rotary movements. Their study, published in Journal of Endodontics, suggests that adaptive movement of nickel-titanium (NiTi) files improves the success rate of root canal treatment by lowering the torque generation of the instruments. A lower torque will help reduce the risk of tooth damage and file fracture.

As shown in this infographic, adaptive movement of the NiTi files was better than continuous rotary movement; this was reflected in lower total torque (Ncm) and shorter preparation times (seconds)
As shown in this infographic, adaptive movement of the NiTi files was better than continuous rotary movement; this was reflected in lower total torque (Ncm) and shorter preparation times (seconds)

Over the years, root canal dental work has been improved with the use of engine-driven NiTi files. Compared with stainless-steel manual files, NiTi instruments offer better flexibility and cutting efficiency, in addition to reduced iatrogenic errors. However, the NiTi files may have cyclic fatigue and torsional failure problems during the root canal procedure. To reduce the risk of file fracture, Dr. Kwak tested heat-treated NiTi alloy files with specially designed rotary movements.

The scientists tested three types of instruments/movements for the root canal procedure:  The K3XF rotary system with 1) continuous rotary movement (XFC) or 2) adaptive movement (XFA), and 3) the Twisted File with adaptive movement (TFA), all from the endodontic product manufacturer Kerr Endodontics. "Adaptive motion" combines continuous and reciprocating (clockwise and counterclockwise directions) movements rotating 600˚, stopping when the file is exposed to minimal or no load. According to Dr Kwak, "Adaptive movement helps to reduce torque generation during instrumentation with NiTi rotary files." Torque generation occurs while removing root dentin by engine-driven NiTi files. The generated torque implies the energy required to cut root dentin, but also represents the reaction stress to NiTi files as well as the root dentin.
To ensure consistent test conditions, endo-training resin blocks—acrylic blocks used in dentistry to simulate a root canal—were used for all instruments. Each block contained an S-shaped artificial canal, with a working length of 16 mm. The instrumental procedure was performed by a single, experienced endodontist to reduce operator errors, for a total of 45 tests (15 per instrument).
The researchers found that TFA generated the lowest torque. Dr. Kwak and colleagues thus concluded that the adaptive movement for NiTi files may reduce torque generation without increasing preparation time. Dr. Kwak also suggests that the "torque generation is more likely to be affected by the cross-sectional area rather than the movement of the file system." A smaller cross-sectional area may account for the lower torque generation in the TFA file system.
These findings are promising for instrumentation in root canal procedures in the future. The next steps would be to assess the feasibility of these improved instruments in real-life situations in patients in the OR, as opposed to the well-controlled laboratory conditions of this study.

Reference  
Titles of original paper: Comparison of In Vitro Torque Generation during Instrumentation with Adaptive Versus Continuous Movement
DOI:
Name of author:
Affiliation:
https://doi.org/10.1016/j.joen.2019.02.010  
Sang Won Kwak
Department of Conservative Dentistry, School of Dentistry, Dental Research Institute, Pusan National University, Yangsan, Korea

Pusan National University website
https://www.pusan.ac.kr/eng/Main.do

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Swift Health Systems Raises $45 Million in Series C Funding


IRVINE, CA., October 8, 2019 – Swift Health Systems, Inc., makers of INBRACE®, today announced the company has raised $45MM in series C funding to help bolster commercialization of INBRACE. Financing was co-led by Vivo Capital, Novo Holdings and venBio Partners and brings the total capital raised by the company to more than $70MM. Series C funds will be directed at broadening commercial availability of the innovative INBRACE solution through expanded orthodontist onboarding and training, increased sales and marketing resources and consumer demand generation programs in support of existing and new INBRACE providers.

The orthodontic industry is experiencing a huge increase in do-it-yourself (DIY) aligner therapy, which is raising concerns among dental professionals over potential health risks from unsupervised treatment. INBRACE addresses both consumer and orthodontist needs in this evolving market, as a discrete, aesthetic and convenient solution that delivers the health benefits of light-force tooth movement.

INBRACE truly invisible braces sit unseen behind patient teeth, leveraging an all-digital platform and innovative wire and bracket designs to create the ideal smile for each patient’s unique situation. Patented INBRACE Smartwires® are programmed using data captured from digital scans of patient teeth and automate many steps in orthodontic treatment. The INBRACE system allows patient anatomy to naturally dictate the most efficient path for all tooth movements, resulting in increased practice efficiency and reduced overall treatment time – a true win-win for patients and orthodontists.

"Vivo is delighted to join the Swift Health Systems team,” said Andrew D. Goldberg, MD, principal at Vivo Capital and future Swift board member. “We believe that the advanced technologies behind INBRACE truly invisible braces will revolutionize the future of orthodontic treatment. The capital raised will enable Swift to advance the ways it supports patients and orthodontists around the globe."

Joining Dr. Goldberg on the Swift board are accomplished med-tech professionals and venture capitalists Peter Moldt, PhD, partner at Novo Ventures; and Aaron Royston, MD, partner at venBio.
 
About Vivo Capital
Vivo Capital (“Vivo”) is a healthcare-focused investment firm formed in 1996 with over $3 billion under management. Vivo is currently making investments out of its growth and private equity fund into promising late-stage private and public healthcare companies in the U.S., Europe, and Greater China, from its Opportunity Fund into promising public healthcare companies, and from its PANDA Fund into promising early-stage innovative healthcare companies. For more information visit http://vivocapital.com/.
 
Novo Holdings A/S is a private limited liability company wholly owned by the Novo Nordisk Foundation. It is the holding and investment company of the Novo Group, comprising of Novo Nordisk A/S and Novozymes A/S, and is responsible for managing the Novo Nordisk Foundation’s assets. Novo Holdings is recognized as a leading international life science investor, with a focus on creating long-term value. As a life science investor, Novo Holdings provides seed and venture capital to development-stage companies and takes significant ownership positions in growth and well-established companies. Novo Holdings also manages a broad portfolio of diversified financial assets. Novo Ventures is a wholly owned subsidiary of, and provides certain consulting services to, Novo Holdings. For more information visit: www.novoholdings.dk.
 
About venBio
venBio Partners is a life sciences investment firm that partners with industry leaders to build innovative medicines and technologies, with a focus on novel therapeutics for unmet medical needs. For more information, please visit www.venbio.com.
 
About INBRACE
Hidden behind your teeth, INBRACE® is the new name for truly invisible braces and the aesthetic solution that patients love and doctors trust. The patented Smartwire® system with GentleforceTM technology is tailored to each patient’s unique smile, promoting good oral health through light-force tooth movement and allowing patients to brush and floss normally. Orthodontists appreciate the health benefits of light-force tooth movement and the practice growth opportunities that INBRACE creates. Learn more at www.myinbrace.com or connect with your nearest INBRACE provider with the easy-to-use doctor finder at www.myinbrace.com/doctor-finder.
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