Effectiveness of adjunct therapy for the treatment of apical periodontitis: A systematic review and meta‐analysis

Abstract

BackgroundAdjunct therapy refers to any intracanal procedure going beyond chemomechanical preparation with instruments and traditionally delivered irrigants (excluding interim dressings). It is not clear whether and which of these adjunct therapies have a significant impact on the outcome of root canal treatment [healing of apical periodontitis (AP) and other patient‐related outcomes].ObjectivesThis systematic review aimed to analyse available evidence on the effectiveness of adjunct therapy for the treatment of AP in permanent teeth, according to a population, intervention, comparison, outcome, time and study design framework formulated a priori by the European Society of Endodontology.MethodsFive electronic databases (PubMed, Embase, Scopus, Cochrane and Web of Science) were searched up to October 2021 to identify clinical studies comparing adjunct therapy to no adjunct therapy in adult patients with AP. Animal studies, reviews, studies with less than 10 patients per arm and studies with a follow‐up time of less than 1 year, or less than 7 days for postoperative pain, were excluded. The quality of the included studies was appraised by the appropriate tools [Risk of Bias 2 (RoB2) for randomized clinical trials (RCTs) and Newcastle–Ottawa Scale for observational studies]. Meta‐analysis was performed using a random‐effects model. The certainty of the evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach.ResultsFourteen studies (13 RCTs and one retrospective cohort) fulfilled the inclusion criteria for this review. They evaluated different types of adjunct therapy: antimicrobial photodynamic therapy (aPDT; three studies), diode laser canal irradiation (3), Nd:YAG laser canal irradiation (2), Er;Cr:YSGG laser canal irradiation (1), ozone therapy (2) and ultrasonically activated irrigation (UAI) (4). Radiographical healing was reported in seven studies, but meta‐analysis was only possible for UAI (two studies), showing no statistically significant difference in healing after 12 months. Pain after 7 days was reported in seven studies. Meta‐analysis on three studies that used aPDT and on two studies using diode laser irradiation showed no significant difference in the prevalence of pain after 7 days between the control and adjunct therapy. According to RoB2 tool, six studies had a high risk of bias, five studies had some concerns, and two studies low risk of bias. The GRADE assessment revealed a very low strength of evidence for diode laser, and low strength of evidence for PDT, ozone and UAI studies.DiscussionThe included studies displayed significant heterogeneity in terms of type of adjunct therapy, technical details per adjunct therapy, outcome reporting and several combinations of these, limiting the potential for meta‐analysis.ConclusionsThere is insufficient evidence to recommend any adjunctive therapy for the treatment of apical periodontitis.RegistrationProspero CRD42021261869.

Continuous Wave of Condensation Improves the Filling of Curved Canals: a Micro-CT Study

“…The success of endodontic treatment depends on the control of endodontic infection of the root canal system (1). The ideal filling technique should fill the root canal three-dimensionally, including areas with irregularities and isthmus (2), in order to favor the prognosis (3).…”

“…However, cold gutta-percha may not allow adaptation to the irregularities of root canals, allowing the presence of voids between the gutta-percha cones and root canal (10,11). To overcome these disadvantages, thermoplastic root canal obturation methods are proposed (1,12,13).…”

Treatment of pulpal and apical disease: The European Society of Endodontology (ESE) S3‐level clinical practice guideline

“…For this guideline, a total of 14 systematic reviews (SRs) were conducted to support the guideline development process (Bucchi et al, 2022; Bürklein & Arias, 2022; Corbella et al, 2022; Donnermeyer et al, 2022; Hilmi et al, 2023; Jakovljevic et al, 2022; Meire et al, 2022; Meschi et al, 2022; Pirani & Camilleri, 2022; Plotino et al, 2022; Rossi‐Fedele & Ng, 2022; Rossi‐Fedele & Rödig, 2022; Tomson et al, 2022; Widbiller et al, 2022). Each SR has two designated senior reviewers, who were from different countries and institutions and were not established collaborators, to work together on each review.…”

Irrigants and irrigation activation systems in Endodontics

“…According to Meire et al 114 , a popular form of adjunct therapy is represented by the use of light. The first approach is the use of laser light for direct canal wall irradiation, where the canal walls are exposed to irradiation with laser light of a particular wavelength, typically in the absence of an irrigant.…”

“…Moreover, other techniques use ozone-generating devices to get the same premises 68 , 69 , 70 , 71 , 72 , 73 , 74 . A systematic review on the effectiveness of adjunct therapy for the treatment of apical periodontitis 114 aimed to critically appraise all available evidence regarding the efficacy of adjunct therapy in decreasing the occurrence of clinical and radiographic features and contributing to increase the success rate of the endodontic treatment. The authors could not find the superiority of the adjunct therapies evaluated over conventional ones in enhancing root canal disinfection, meaning that up to the moment, the endodontic treatment performed today can reduce the microbial load of the root canals, allowing repair of the periapical lesion.…”