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Clinical and Experimental Approaches in Dental Health

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A special issue of International Journal of Environmental Research and Public Health (ISSN 1660-4601). This special issue belongs to the section "Digital Health".

Deadline for manuscript submissions: closed (28 February 2023) | Viewed by 25189

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Dr. Aida Meto

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Department of Dentistry, Faculty of Dental Sciences, University of Aldent, 1007 Tirana, Albania
Interests: oral pathogens; dental infections; parodontology; orthodontics; endodontics
Special Issues, Collections and Topics in MDPI journals

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Dear Colleagues,

I would like to invite you to submit your precious research/work to this Special Issue on “Clinical and Experimental Approaches in Dental Health” in IJERPH! To make your contribution as valuable as possible, original scientific papers, reviews, short communications and case reports will be considered. As a branch of Medicine, Dentistry is acquiring great importance because of the continuous updates in new materials and technologies, being proposed as efficacious tools in dental/oral health promotion. Also, increasing evidence underlines the relevance of both local and distal parameters (oral hygiene, dental appliances, diet, systemic diseases, drugs, etc.) on oral health and its homeostasis. In this respect, the growing interest on natural compounds and probiotics, opens new scenarios on dental/oral care, also taking into account the unsolved problem of antimicrobial resistance. Accordingly, in this SI, articles including novel materials, compounds, devices or technologies to promote healthcare, from all fields of dentistry, are welcome to be submitted.

Dr. Aida Meto
Guest Editor

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Keywords

oral pathogens
microbial biofilm
oral diseases
dental infections
clinical dentistry
oral surgery
orthodontics
dental implantology
restorative materials
dental biomaterials
probiotics
natural components
regenerative medicine
biomimetic materials

Published Papers (12 papers)

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Research

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11 pages, 6072 KiB

Open AccessArticle

MALDI-TOF/MS Profiling of Whole Saliva and Gingival Crevicular Fluid in Patients with the Invisalign System and Fixed Orthodontic Appliances

by Peter Bober, Ivan Talian, Dávid Mihalik, Gabriela Verbová and Ján Sabo

Int. J. Environ. Res. Public Health 2023, 20(4), 3252; https://0-doi-org.brum.beds.ac.uk/10.3390/ijerph20043252 - 13 Feb 2023

Viewed by 1489

Abstract

The movement of teeth by orthodontic treatment with the Invisalign (IN) system and fixed orthodontic appliances (FOA) is characterized by the reconstruction of periodontal ligaments, alveolar bone, and gingiva. A reflection of these phenomena can be found in the composition of gingival crevicular fluid (GCF). A total of 90 samples from 45 participants (45 whole saliva and 45 GCF), including 15 patients with FOA, 15 patients with IN, and 15 patients with oral health, were subjected to matrix-assisted laser desorption/ionization mass spectrometry (MALDI-TOF/MS) analysis. Mass fingerprints were generated for each sample. Three models were tested: a quick classifier (QC), a genetic algorithm (GA), and a supervised neural network (SNN). For both groups of samples (saliva and GCF), the GA model showed the highest recognition abilities of 88.89% (saliva) and 95.56% (GCF). Differences between the treated (FOA and IN) groups and the control group in saliva and GCF samples were determined using cluster analysis. In addition, we monitored the effect of long-term orthodontic treatment (after 6 months) in the lag phase of orthodontic tooth movement. The results show increased levels of inflammatory markers (α-defensins), which may indicate an ongoing inflammatory process even after 21 days from force application. Full article

(This article belongs to the Special Issue Clinical and Experimental Approaches in Dental Health)

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7 pages, 2674 KiB

Open AccessArticle

Effect of Amnioguard and Biomesh GTR Membranes with Novabone Putty in the Treatment of Periodontal Osseous Defects—A Communication

by Priyankar Chakraborthy, Potluri Leela Ravishankar, Anbukumari Vadivelu Saravanan, Khalid J. Alzahrani, Ibrahim F. Halawan, Saleh Alshammeri, Mrim M. Alnfiai, Hosam Ali Baeshen, Sarah Yasser M. Qattan, Ammar Almarghlani, Sunanda Rao Karkala, Anila Neelakandan and Shankargouda Patil

Int. J. Environ. Res. Public Health 2023, 20(1), 816; https://0-doi-org.brum.beds.ac.uk/10.3390/ijerph20010816 - 1 Jan 2023

Cited by 1 | Viewed by 1914

Abstract

(1) Background: Guided tissue regeneration was an effective surgical procedure in the management of intrabony defects and has undergone a number of changes in terms of materials and techniques. The aim of this study is to compare AmnioGuard and BioMesh in combination with NovaBone putty in intrabony defects. (2) Methodology: Ten patients who needed regenerative periodontal therapy were randomly allocated into two groups based on the inclusion criteria. These patients were subjected to phase I therapy followed by which Group A patients were treated with AmnioGuard + NovaBone putty whereas Group B with BioMesh + NovaBone putty. The clinical indices were obtained at baseline, 3 months and 6 months post-operatively while radiographic parameters were obtained at 6 months post-op. (3) Results & Conclusion: At six months after surgery, Group B (33% bone gain) showed a statistically significant change from Group A (16% bone gain) in both the clinical and radiographic measures (p < 0.05). Full article

(This article belongs to the Special Issue Clinical and Experimental Approaches in Dental Health)

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10 pages, 1360 KiB

Open AccessArticle

Morphological Characteristics and Prevention of Tooth Enamel Demineralization during Orthodontic Treatment with Non-Removable Appliances

by Gagik Khachatryan, Marina Markaryan, Izabella Vardanyan, Mikayel Manrikyan and Gayane Manrikyan

Int. J. Environ. Res. Public Health 2023, 20(1), 540; https://0-doi-org.brum.beds.ac.uk/10.3390/ijerph20010540 - 29 Dec 2022

Cited by 1 | Viewed by 1565

Abstract

Despite the large number of studies on the effect of braces on teeth, there is no information on the dynamics of the state of the ultrastructure of the hard tissues of teeth during orthodontic treatment. The purpose of this study is to examine the state of the hard tissues of the teeth and carry out preventive measures to reduce the risk of complications in the process of orthodontic treatment using a non-removable device. Methods: For the in vitro study, 68 teeth were randomly divided into group A—no prophylactic treatment, and group B—treated with the fluorine varnish Tiefenfluorid. After 35 days, all the teeth were prepared for microscopic examination. The clinical study included 59 patients aged 12–17 years with orthodontic brackets. The split-mouth technique was used. The areas around the bracket of one-half of the oral cavity were treated with Tiefenfluorid every 6 months during the entire treatment period. The teeth of the second half of the oral cavity served as the control group. The data were processed in the SPSS19 package. Results: In vitro and clinical study results showed a statistically significant difference between the prophylactic and control groups of teeth in favor of the prophylactic group, where the statistical significance was p ≤ 0.01. Full article

(This article belongs to the Special Issue Clinical and Experimental Approaches in Dental Health)

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9 pages, 3375 KiB

Open AccessArticle

In-Vitro Assessment of the Corrosion Potential of an Oral Strain of Sulfate-Reducing Bacteria on Metallic Orthodontic Materials

by Umarevathi Gopalakrishnan, Kavitha Thiagarajan, A. Sumathi Felicita, Pallabhi Gosh, Abdulrahman Alshehri, Wael Awadh, Khalid J. Alzahrani, Fuad M. Alzahrani, Khalaf F. Alsharif, Ibrahim F. Halawani, Saleh Alshammeri, Ahmed Alamoudi, Dhalia H. Albar, Hosam Ali Baeshen and Shankargouda Patil

Int. J. Environ. Res. Public Health 2022, 19(22), 15312; https://0-doi-org.brum.beds.ac.uk/10.3390/ijerph192215312 - 19 Nov 2022

Cited by 2 | Viewed by 1430

Abstract

Aim: Orthodontic literature is scant when it comes to microbial corrosion. The oral prevalence of many bacteria which are capable of causing microbial corrosion is reported in the dental literature. The aim of this study is to experimentally determine the corrosive potential of an oral strain of Sulfate-reducing bacteria. Materials and Methods: Stainless steel (SS) bracket, stainless steel archwire, NiTi archwire, Titanium molybdenum (TMA) archwire, and titanium miniscrew were immersed in five media which included Artificial saliva (group I), Sulfate rich artificial saliva (group II), API agar medium specific for SRB (group III), AS + API medium+ bacterial strain (group IV), SRAS+ API medium+ bacterial strain (group V). The materials were then subjected to Scanning electron microscopy and energy-dispersive X-ray analysis (EDX). Results: Materials in groups I, II, and III did not show any surface changes whereas materials in groups IV and V which contained the bacteria showed surface changes which were erosive patches suggestive of corrosion. EDX analyses were in line with similar findings. Conclusion: This in vitro study suggested that the oral strain of Sulfate-reducing bacteria was able to induce corrosive changes in the experimental setup. Full article

(This article belongs to the Special Issue Clinical and Experimental Approaches in Dental Health)

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15 pages, 2724 KiB

Open AccessArticle

Physical, Optical, and Mechanical Properties of Ceramic Materials after Coffee Immersion and Evaluation of Cleaning Impact with Different Oral Hygiene Tools

by Nasser M. Al Ahmari, Maram A. Alahmari, Mohammed M. Al Moaleem, Raghad S. A. Alshahrani, Fatimah F. Alqahtani, Waad Saeed Mohammed, Bandar M. A. Al-Makramani, Vini Mehta, Aida Meto and Agron Meto

Int. J. Environ. Res. Public Health 2022, 19(22), 15047; https://0-doi-org.brum.beds.ac.uk/10.3390/ijerph192215047 - 15 Nov 2022

Cited by 2 | Viewed by 1933

Abstract

This study aimed to evaluate the effect of three oral hygiene tools, a regular toothbrush, an electronic toothbrush, and mouthwash, on the color stability of three different computer-aided design (CAD) and computer-aided manufactured (CAM) ceramic blocks. Feldspathic ceramic (Vita Triluxe Forte), hybrid resin ceramic (Vita Enamic), and lithium disilicate glass-ceramic (IPS e.max CAD) were used in this study. A CAD/CAM system and 81 (27 of each material) samples of ceramic blocks were used. All samples were immersed in black coffee for 15 days, and the coffee was changed twice per day. Using a spectrophotometer probe, samples on a grey background were scanned, and physical properties like surface hardness and depth were measured using interferometry and a 3D non-contact surface metrology. After 30 days of application of oral hygiene tools, instruments were used to measure various physical, mechanical, and optical properties. Vita Triluxe had the highest average color variation values (ΔE₀₀) after 15 and 30 days of immersion in coffee in both regular and electronic toothbrushes. Moreover, IPS e.max CAD had the least ΔE₀₀ values with no significant differences among the groups. The surface roughness (Ra) of the Vita Enamic ceramic increased when using a regular toothbrush, and the surface height (Rz) for the Vita Enamic ceramic increased when an electronic toothbrush was used. IPS e.max CAD had the greatest modules of elasticity forces, and Vita Triluxe Forte had the lowest when used with a regular toothbrush. The ΔE₀₀ values of the tested materials were minimally increased or decreased after 30 days of cleaning, and all were clinically acceptable. Ra and Rz were the highest for Vita Enamic in comparison to the other groups. The highest percentage in IPS e.max CAD was associated with a type 1 fracture, whereas type 3 was predominantly observed with Vita Enamic, and type 2 in the Vita Triluxe group without significant differences. Full article

(This article belongs to the Special Issue Clinical and Experimental Approaches in Dental Health)

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12 pages, 972 KiB

Open AccessArticle

Pomegranate Extract Affects Fungal Biofilm Production: Consumption of Phenolic Compounds and Alteration of Fungal Autoinducers Release

by Bruna Colombari, Davide Tagliazucchi, Alessandra Odorici, Eva Pericolini, Ismaela Foltran, Diego Pinetti, Aida Meto, Samuele Peppoloni and Elisabetta Blasi

Int. J. Environ. Res. Public Health 2022, 19(21), 14146; https://0-doi-org.brum.beds.ac.uk/10.3390/ijerph192114146 - 29 Oct 2022

Cited by 3 | Viewed by 1637

Abstract

Candida albicans expresses numerous virulence factors that contribute to pathogenesis, including its dimorphic transition and even biofilm formation, through the release of specific quorum sensing molecules, such as the autoinducers (AI) tyrosol and farnesol. In particular, once organized as biofilm, Candida cells can elude conventional antifungal therapies and the host’s immune defenses as well. Accordingly, biofilm-associated infections become a major clinical challenge underlining the need of innovative antimicrobial approaches. The aim of this in vitro study was to assess the effects of pomegranate peel extract (PomeGr) on C. albicans growth and biofilm formation; in addition, the release of tyrosol and farnesol was investigated. The phenolic profile of PomeGr was assessed by high-performance liquid chromatography coupled to electrospray ionization mass spectrometry (HPLC-ESI-MS) analysis before and after exposure to C. albicans. Here, we showed that fungal growth, biofilm formation and AI release were altered by PomeGr treatment. Moreover, the phenolic content of PomeGr was substantially hampered upon exposure to fungal cells; particularly pedunculagin, punicalin, punicalagin, granatin, di-(HHDP-galloyl-hexoside)-pentoside and their isomers as well as ellagic acid–hexoside appeared highly consumed, suggesting their role as bioactive molecules against Candida. Overall, these new insights on the anti-Candida properties of PomeGr and its potential mechanisms of action may represent a relevant step in the design of novel therapeutic approaches against fungal infections. Full article

(This article belongs to the Special Issue Clinical and Experimental Approaches in Dental Health)

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6 pages, 577 KiB

Open AccessCommunication

Novel Options to Counteract Oral Biofilm Formation: In Vitro Evidence

by Alessandra Odorici, Bruna Colombari, Pierantonio Bellini, Aida Meto, Irene Venturelli and Elisabetta Blasi

Int. J. Environ. Res. Public Health 2022, 19(13), 8056; https://0-doi-org.brum.beds.ac.uk/10.3390/ijerph19138056 - 30 Jun 2022

Cited by 7 | Viewed by 1339

Abstract

Biofilm production on biotic and abiotic surfaces is crucial in the pathogenesis of most infections, particularly those occurring in the oral cavity. Its prevention and/or control may greatly facilitate the management of patients with oral diseases. Here, the antibiofilm activity of a biomimetic hydroxyapatite and a natural compound, MicroRepair (MicroR) and pomegranate (PomeGr), respectively, was assessed. By luminescence/fluorescence-based assays, Pseudomonas aeruginosa (P. aeruginosa), Staphylococcus aureus (S. aureus) and Candida albicans (C. albicans) were tested for biofilm production in the presence of MicroR and/or PomeGr. We found that both MicroR and PomeGr could affected biofilm production; however, the efficacy of the two, given alone or in combination, varied according to the microbial agent considered. These data open to clinical studies aimed at defining the most efficacious protocols to counteract oral biofilm-associated infections. Full article

(This article belongs to the Special Issue Clinical and Experimental Approaches in Dental Health)

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Review

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11 pages, 899 KiB

Open AccessReview

Hyaluronic Acid: A New Approach for the Treatment of Gingival Recession—A Systematic Review

by Vini Mehta, Gerta Kaçani, Mohammed M. Al Moaleem, Anwar Abdulkarim Almohammadi, Malak Mohammed Alwafi, Abduljabbar Khalil Mulla, Shahad Owaidh Alharbi, Abdullah Waleed Aljayyar, Etleva Qeli, Çeljana Toti, Agron Meto and Luca Fiorillo

Int. J. Environ. Res. Public Health 2022, 19(21), 14330; https://0-doi-org.brum.beds.ac.uk/10.3390/ijerph192114330 - 2 Nov 2022

Cited by 3 | Viewed by 2810

Abstract

This systematic review aimed to investigate the effectiveness of hyaluronic acid (HA) on the clinical treatment outcomes of patients with gingival recession. A systematic search was performed in PubMed, Cochrane Central Register of Controlled Trials, Embase, Scopus, and Google Scholar for studies up to 15 August 2022. Two reviewers separately selected the papers for eligibility after conducting a thorough search. The study includes randomized controlled clinical trials in which participants were given HA in addition to periodontal treatment surgical procedures. The changes following the treatment protocol were evaluated for complete and mean root coverage as a primary outcome and gingival recession gain as the secondary outcome. Three articles met the eligibility criteria out of 557 titles. In periodontal surgery, HA exhibited better results in complete root coverage and mean root coverage when compared to the control group. Gingival recession reduction, clinical attachment level, and keratinized tissue gain were significantly increased compared to the control groups. However, the comparison presented in the following study might show heterogeneity among the studies and risk of bias in general. Given the scope of this analysis, results suggest that adjunctive treatment with HA gel for root coverage could be clinically beneficial. Full article

(This article belongs to the Special Issue Clinical and Experimental Approaches in Dental Health)

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Other

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13 pages, 611 KiB

Open AccessSystematic Review

Evaluation of Root Anatomy and Canal Configuration of Human Permanent Maxillary First Molar Using Cone-Beam Computed Tomography: A Systematic Review

by Sourabh Barbhai, Rajesh Shetty, Poonam Joshi, Vini Mehta, Ankita Mathur, Tanvi Sharma, Damini Chakraborty, Priyanka Porwal, Aida Meto, Dian Agustin Wahjuningrum, Alexander Maniangat Luke and Ajinkya M. Pawar

Int. J. Environ. Res. Public Health 2022, 19(16), 10160; https://0-doi-org.brum.beds.ac.uk/10.3390/ijerph191610160 - 16 Aug 2022

Cited by 9 | Viewed by 2098

Abstract

The aim of this paper is to review the literature on root canal configuration (RCC) and the frequency of occurrence of a second mesiobuccal canal (MB) in human permanent maxillary first molars where cone-beam computed tomography (CBCT) is used. Online electronic databases such as PubMed-Medline, Embase, Scopus and Cochrane Library were searched using appropriate keywords from the earliest available date until 12th June 2022, without restriction on language. In the mesiobuccal root, type I was the most frequent (33.29%), followed by types II and IV (27.18% and 26.36%, respectively). Moreover, 68.2% of maxillary first molars had a second MB canal. For both the distobuccal and palatal roots, type I was the most prevalent, with 99.08% and 97.83% occurrence, respectively. All other types were infrequent. Type I RCC is most frequent in all the roots of the maxillary first molars. Hence, care must be taken during biomechanical preparation of the MB roots. Full article

(This article belongs to the Special Issue Clinical and Experimental Approaches in Dental Health)

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20 pages, 3266 KiB

Open AccessSystematic Review

Diagnostic Accuracy of Pulp Vitality Tests and Pulp Sensibility Tests for Assessing Pulpal Health in Permanent Teeth: A Systematic Review and Meta-Analysis

by Swadheena Patro, Agron Meto, Ankita Mohanty, Viresh Chopra, Sanjay Miglani, Antarikshya Das, Alexander Maniangat Luke, Dunia Al Hadi, Aida Meto, Luca Fiorillo, Mohmed Isaqali Karobari, Dian Agustin Wahjuningrum and Ajinkya M. Pawar

Int. J. Environ. Res. Public Health 2022, 19(15), 9599; https://0-doi-org.brum.beds.ac.uk/10.3390/ijerph19159599 - 4 Aug 2022

Cited by 11 | Viewed by 4094

Abstract

The current systematic review and meta-analysis was carried out to compare the diagnostic accuracy of pulp vitality and pulp sensibility tests in assessing pulpal health. PubMed/MEDLINE, Cochrane Central Register of Controlled Trials, Web of Science, Google Scholar and Open Grey databases were searched and after assessing eligibility criteria the data were extracted. True-positive, false-positive, true-negative, false-negative, sensitivity and specificity values were extracted or calculated if not presented. Quality of studies was evaluated based on the QUADAS 2 tool. Meta-analysis was performed in MetaDTA (v2.0; Shinyapps, RStudio PBC, Boston, MA, USA) and Review Manager 5.3 (RevMan web; The Cochrane Collaboration, London, UK). Ten articles were included for qualitative synthesis and five for meta-analysis. The pooled diagnostic odds ratio for pulse oximeter (PO), electric pulp tester (EPT), cold test (CT) and heat test (HT) was 628.5, 10.75, 17.24 and 3.47, respectively. Pairwise comparison demonstrated a higher pooled mean sensitivity and specificity with PO compared with EPT. Comparison between PO and CT and between PO and HT also demonstrated a higher pooled mean sensitivity and specificity for PO. Summary points on receiver operating characteristic curves confirmed the ability of PO to correctly screen negatives in presenting patients as compared to EPT, CT and HT but no study was rated as good on quality assessment. PO can be considered as the most accurate diagnostic method as compared to EPT, CT and HT. This review provides information about the reliability and diagnostic accuracy of using pulp vitality and sensibility tests for assessing pulp status. Full article

(This article belongs to the Special Issue Clinical and Experimental Approaches in Dental Health)

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10 pages, 1905 KiB

Open AccessBrief Report

Transcription Factor AhR, Cytokines IL-6 and IL-22 in Subjects with and without Peri-Implantitis: A Case Control-Study

by Luis Ricardo Linard Martins, Kinga Grzech-Leśniak, Nidia Castro dos Santos, Lina J. Suárez, Gabriela Giro, Marta Ferreira Bastos and Jamil Awad Shibli

Int. J. Environ. Res. Public Health 2022, 19(12), 7434; https://0-doi-org.brum.beds.ac.uk/10.3390/ijerph19127434 - 17 Jun 2022

Cited by 3 | Viewed by 1852

Abstract

Peri-implantitis is a plaque-associated condition characterized by mucosal inflammation and subsequent progressive loss of supporting bone; it is caused by bacterial biofilm, but the host response triggered by bacterial stimulation promotes the release of cells and mediators that culminate in tissue destruction. The Aryl-hydrocarbon Receptor (AhR) is associated with IL-22 production by Th22 and Th17 CD4+ Th cells. The presence of IL-6 may promote the Th22 phenotype. The present case-control study evaluated the gene expression of AhR, IL-22, and IL-6 in the peri-implant tissues of healthy and peri-implantitis patients. Tissue biopsies were collected from thirty-five volunteers (15 healthy and 20 with peri-implantitis). A real-time PCR reaction was utilized to assess the AhR, IL-22, and IL-6 gene expression levels relative to the reference gene (GAPDH). The results were analyzed using the Mann–Whitney test with a significance level of 5%. Higher levels of gene expression of AhR and IL-6 were detected in peri-implantitis tissues. The IL-22 gene expression levels did not differ between groups. In conclusion, higher gene expression levels for AhR and IL-6 were detected in the soft tissues of peri-implantitis patients. IL-22 did not vary between conditions, which may indicate the loss of the immunomodulatory role of IL-22 in periimplantitis. Full article

(This article belongs to the Special Issue Clinical and Experimental Approaches in Dental Health)

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15 pages, 1131 KiB

Open AccessSystematic Review

Herbal Agents versus Ethylene Diamine Tetra Acetic Acid on Removal of the Smear Layer—A Systematic Review of In Vitro Studies

by Kavalipurapu Venkata Teja, Krishnamachari Janani, Abdullah Ali Alqahtani, Ali Robaian, Feras Alhalabi, Khalid A. Merdad, Mohammad Khursheed Alam, Deepti Shrivastava, Jerry Jose and Kumar Chandan Srivastava

Int. J. Environ. Res. Public Health 2022, 19(11), 6870; https://0-doi-org.brum.beds.ac.uk/10.3390/ijerph19116870 - 3 Jun 2022

Cited by 5 | Viewed by 2137

Abstract

This systematic review aimed to compare the efficacy of herbal agents with ethylene diamine tetraacetic acid (EDTA) in removing the smear layer during root canal instrumentation. The research question in the present study was to assess: “Is there a significant difference in reducing smear layer comparing EDTA and herbal agents?” Electronic databases (PubMed, Scopus, and Web of Science) were searched from their start dates to April 2022 using strict inclusion and exclusion criteria, and reviewed following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2020 guidelines. Only in vitro studies comparing herbal agents with EDTA were included in the current systematic review. Two reviewers independently assessed the included articles. A total of 625 articles were obtained from an electronic database. Eighteen papers were included for review of the full text, out of which, ten papers were excluded because they did not meet the inclusion criteria. Finally, eight articles were included in the systematic review. The present systematic review considered only in vitro studies; hence, the result cannot be completely translated to strict clinical conditions. The results of the present systematic review have shown that quixabeira, morindacitrifolia, oregano extract, and neem show better smear layer removal compared to other herbal agents, whereas they showed reduced smear layer removal when compared with EDTA. Although, it was seen that most of the included studies did not report a high quality of evidence. Hence, the present systematic review concludes that herbal agents have reported to show inferior smear layer removal when compared to EDTA. Thus, as far as herbal based alternatives are concerned, there is no highest level of evidence to state its real benefit when used as a chelating root canal irrigant. Full article

(This article belongs to the Special Issue Clinical and Experimental Approaches in Dental Health)

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