Interventions for Early-Stage Pericoronitis

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1		Anna Carolina Ratto Tempestini Horliana	+ 1359 word(s)	1359	2022-01-10 07:42:43	\|
2	done	Jason Zhu	Meta information modification	1359	2022-02-21 03:23:46	\| \|
3	Done	Jason Zhu	+ 43 word(s)	1402	2022-02-21 03:25:55	\|

This entry is adapted from the peer-reviewed paper 10.3390/antibiotics11010071

Evidence of low methodological quality and high clinical diversity showed that there are still uncertainties to estimate the effect of the different interventions for pericoronitis. It is important to note that pericoronitis is an inflammation of the tissues around the crown. Until now, initial pericoronitis should be resolved with local irrigation and gently debridement. Antibiotics should be specially reserved for severe cases when systemic dissemination are present.

Intervention Pericoronitis drug

1. Introduction

Pericoronitis is the common term used to describe the inflammation of soft tissues around the dental crown in a semi-erupted lower third molar ^[1]. The pseudo-pocket formed around the third molar accumulates bacterial plaque underneath the soft tissue cap, predisposing to inflammatory complications ^[2]^[3]. Usually, patients with early stage pericoronitis report: pain, intra-oral swelling, redness, mucosal ulceration, and loss of function ^[4]. Its cure is easy, quick, cheap, and no need for systemic antibiotics if detected early and appropriately treated ^[3]. Proper treatment of the initial phase is the local therapy over antibiotic prescribing ^[3]. Antibiotics should be reserved for severe cases where the spread of infection with systemic symptoms are present ^[5] because of the risk of developing resistance ^[6]. However, a large proportion of dentists routinely prescribe unnecessary antibiotics for pericoronitis ^[7]. The problem is the lack of evidence-based standardized treatment for initial pericoronitis ^[3].

It is well known that the evolution of the initial condition causes lymphadenopathy, fever, malaise, palatoglossal arch asymmetry, difficulty swallowing and trismus, indicating a more severe course of this condition ^[3] and may lead to a life-threatening condition called Ludwig’s angina ^[8]. Pericoronitis complications resulting in severe emergencies and must be treated in a hospital, with antibiotic cover. Unfortunately, antibiotics were prescribed to more than half of patients with pericoronitis, and, pericoronitis was among the top two in the frequency of antibiotic use ^[3]. The problem is the lack of evidence-based standardized treatment for initial pericoronitis, and evidence-based recommendations for its condition is not available until now. To date, there are no systematic reviews that have evaluated the best option treatment for initial pericoronitis, and it remains uncertain due to the lack of evidence.

2. Effects of Intervention

2.1. Comparison 1. Pharmacological Treatment: Oral vs. Topic

One RCT ^[9] (40 participants) compared diclofenac capsule (associated to a placebo spray) with topical benzydamine (associated to placebo capsule) and evaluated the following outcomes immediately after seven days of treatment:

Any adverse events: diclofenac group presented lesser adverse events (gastrointestinal symptoms) than benzydamine (oral numbness and taste alterations), but there was an imprecise estimate of effect with a wide confidence interval, small sample size and reduced number of events (2/20 versus 11/20; Risk ratio (RR) 0.19 95% CI 0.05 to 0.72, p = 0.01).
Quality of life (OHQoL questionnaire): better quality of life in favors of benzydamine (MD −1.10 points, 95% CI −1.85 to −0.35, p = 0.004).

The same RCT ^[9] also compared flurbiprofen capsule (associated to a placebo spray) with topical benzydamine (associated to placebo capsule) after seven days of treatment:

Any adverse events: flurbiprofen group presented lesser adverse events than benzydamine, but there was an imprecise estimate of effect with a wide confidence interval, small sample size and reduced number of events (4/20 versus 11/20; Risk ratio (RR) 0.36 95% CI 0.14 to 0.95, p = 0.04).
Quality of life (OHQoL questionnaire): no difference between groups (MD −0.55 points, 95% CI −1.18 to 0.08, p = 0.09).

Another RCT ^[10] (12 participants) compared penicillin with iodoform gauze drain associated with hot saline irrigations and reported fewer adverse events in the penicillin group (3 participants with gastric distress complaints) compared to no event in the iodoform group after six days of treatment. However, an uncertain estimated effect was due to the wide confidence interval and the lower number of participants and events (RR 7.00, 95% CI 0.44 to 111.91, p = 0.17).

2.2. Comparison 2. Different Oral Pharmacological Treatments

One RCT ^[9] (40 participants) compared diclofenac with flurbiprofen and evaluated the following outcomes immediately after seven days of treatment:

Any adverse events: two participants in the diclofenac group and four in the flurbiprofen group reported gastrointestinal symptoms. The estimated effects are imprecise with a wide confidence interval and reduced number of events (2/20 versus 4/20; Risk ratio (RR) 0.50 95% Confidence interval (CI) 0.10 to 2.43, p = 0.39).
Quality of life (OHQoL questionnaire): no difference was observed between groups (Mean difference (MD) 0.55 points, 95% CI −0.29 to 1.39, p = 0.20).

Another RTC ^[11] (31 participants) compared metronidazole versus phenoxymethylpenicillin and evaluated the following outcomes immediately after five days of treatment:

Pain: lesser metronidazole participants presented pain when compared to phenoxymethylpenicillin. The estimated effect seems to show no difference between groups, but these are imprecise due to the wide confidence interval and the reduced number of participants and events (2/13 versus 1/18; Risk ratio (RR) 2.77 95% CI 0.28 to 27.4, p = 0.38).
Trismus: the authors reported a final mean open mouth of 39.8 mm in the metronidazole group compared to 43 mm in the phenoxymethylpenicillin group (p > 0.05). It was not possible to calculate the mean difference because no standard deviation was provided.

2.3. Comparison 3. Conventional Treatment Associated with Antimicrobial Photodynamic Therapy (aPDT) vs. Conventional Treatment

One RCT ^[12] (59 participants) compared a conventional treatment (debridement, irrigation with warm saline, antiseptic, ibuprofen and instructed on oral hygiene care) associated with aPDT versus only conventional treatment. This study evaluated the following outcomes immediately after 14 days of treatment:

Pain: the estimated effect showed a significant difference in the visual analogue scale favoring conventional treatment (MD 0.40 points 95% CI 0.19 to 0.61, p = 0.0002), but the reduction on the visual analogue scale (0.4 points) was not clinically relevant.
Reduction of pro-inflammatory cytokines: the levels of interleukin 6 (IL-6) presented no difference between groups (MD 2.00 pg/mL 95% CI −10.72 to 6.72, p = 0.65), however, the tumor necrosis factor α (TNF-α) showed a significant reduction in favors of aPDT group (MD −128.00 pg/mL 95% CI −185.47 to −70.53, p < 0.0001), with an imprecise confidence interval.
Microbiological assessment: there was a significant reduction in microbiological counts for both Porphyromonas gingivalis (MD −2.72 CFU/mL 95% CI −3.90 to −1.54, p < 0.00001) and Tannerella forsythia (MD −0.98 CFU/mL 95% CI −1.76 to −0.20, p = 0.01) in favors of aPDT group.
Any adverse events: none of the participants presented any adverse events related to the interventions.

Another RCT ^[13] (40 participants) compared amoxicillin associated with antimicrobial aPDT versus amoxicillin alone and evaluated the following outcomes immediately after three days of treatment:

Pain: The authors reported no difference between the two groups (p = 0.859). It was impossible to calculate the mean difference because the exact mean value was provided only on a graph (approximately 2,3 for both groups). Standard deviation was not provided.
Any adverse events: None of the participants presented any adverse events related to the interventions.

2.4. Comparison 4. Pharmacological Treatment Associated with Laser versus Placebo Laser

One RCT ^[14] assessed pharmacological treatment (amoxicillin trihydrate/potassium clavulanate, acetaminophen and chlorhexidine 0.12%) as co-interventions, associated with different types of laser:

1064-nm Nd: YAG versus placebo laser (40 participants): no difference was observed between groups on the OHQoL questionnaire (MD 1.50 points, 95% CI −2.31 to 5.31), pain reduction (MD 3.50 points 95% CI −9.79 to 16.79), and trismus (MD 1.50 mm, 95% CI −0.41 to 3.41). However, there were wide confidence intervals, and these estimated effects were imprecise.
808-nm diode (GaAlAs) versus placebo laser (40 participants): no difference was observed between groups on the OHQoL questionnaire (MD 2.30 points, 95% CI −0.60 to 5.20), pain reduction (MD −7.70 points 95% CI −17.97 to 3.97), and trismus (MD 0.15 mm, 95% CI −2.04 to 2.34). However, there were wide confidence intervals, and these estimated effects were imprecise.
660-nm diode versus placebo laser (40 participants): no difference was observed between groups on the OHQoL questionnaire (MD 0.25, 95% CI −2.24 to 2.74), pain reduction (MD −0.75 points 95% CI −12.30 to 10.8), and trismus (MD 1.55 mm, 95% CI −0.89 to 3.99). However, there were wide confidence intervals, and these estimated effects were imprecise.

2.5. Comparison 5. Pharmacological Treatment Associated with Different Mouthwashes

One RCT ^[15] (97 participants) assessed the combined use of oral amoxicillin associated with green tea 5% versus amoxicillin associated with chlorhexidine 0.12% mouthwashes. The following outcomes were evaluated after seven days of treatment:

Pain: There was no difference between groups, but these results are imprecise due to a wide confidence interval (MD −1.81 points, 95% CI −3.97 to 0.35).
Trismus: There is no difference between green tea and chlorhexidine (MD 0.87 mm, 95% CI −0.23 to 1.97).

No subgroup nor sensitivity analyses were possible to be performed.

2.6. Assessment of the Certainty of the Evidence

The certainty of the body of the evidence was classified as low to very low, according to the GRADE approach, for all primary outcomes of the most clinically relevant comparison: conventional treatment associated with antimicrobial photodynamic therapy (aPDT) versus conventional treatment. Researchers downgraded this evidence to two levels due to methodological limitations and two due to imprecision (small sample size, single study, and wide confidence interval). The evidence is very uncertain about the effect of conventional treatment associated with aPDT on pain relief and reduction of pro-inflammatory cytokines (very low certainty) compared to conventional treatment alone. For microbiological counts (low certainty), the confidence in the effect estimate is limited (the true effect may be substantially different from the estimate of the effect).

References

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