Meire Maarten A, Bronzato Juliana D, Bomfim Rafael A, Gomes Brenda P F A
Section of Endodontology, Department of Oral Health Sciences, Ghent University, Ghent, Belgium.
Division of Endodontics, Department of Restorative Dentistry, Piracicaba Dental School, State University of Campinas - UNICAMP, Piracicaba, Brazil.
Int Endod J. 2023 Oct;56 Suppl 3:455-474. doi: 10.1111/iej.13838. Epub 2022 Oct 8.
Adjunct 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].
This 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.
Five 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.
Fourteen 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.
The 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.
There is insufficient evidence to recommend any adjunctive therapy for the treatment of apical periodontitis.
Prospero CRD42021261869.
辅助治疗是指任何超出使用器械进行化学机械预备以及传统使用冲洗剂（不包括临时敷料）的根管内操作。目前尚不清楚这些辅助治疗中的任何一种是否以及哪些对根管治疗的结果[根尖周炎（AP）的愈合及其他与患者相关的结果]有显著影响。
本系统评价旨在根据欧洲牙髓病学学会预先制定的人群、干预措施、对照、结局、时间和研究设计框架，分析关于恒牙AP辅助治疗有效性的现有证据。
检索了截至2021年10月的五个电子数据库（PubMed、Embase、Scopus、Cochrane和Web of Science），以确定在成年AP患者中比较辅助治疗与非辅助治疗的临床研究。排除动物研究、综述、每组患者少于10例的研究以及随访时间少于1年或术后疼痛少于7天的研究。使用适当的工具[随机临床试验（RCT）的偏倚风险2（RoB2）和观察性研究的纽卡斯尔-渥太华量表]对纳入研究的质量进行评估。采用随机效应模型进行荟萃分析。使用推荐分级、评估、制定和评价（GRADE）方法评估证据的确定性。
14项研究（13项RCT和1项回顾性队列研究）符合本综述的纳入标准。它们评估了不同类型的辅助治疗：抗菌光动力疗法（aPDT；3项研究）、二极管激光根管照射（3项）、钕：钇铝石榴石激光根管照射（2项）、铒铬：钇-钪-镓石榴石激光根管照射（1项）、臭氧疗法（2项）和超声激活冲洗（UAI）（4项）。7项研究报告了影像学愈合情况，但仅对UAI（2项研究）进行了荟萃分析，结果显示12个月后愈合情况无统计学显著差异。7项研究报告了7天后的疼痛情况。对3项使用aPDT的研究和2项使用二极管激光照射的研究进行的荟萃分析显示，对照治疗和辅助治疗在7天后疼痛发生率方面无显著差异。根据RoB2工具，6项研究存在高偏倚风险，5项研究存在一些问题，2项研究存在低偏倚风险。GRADE评估显示，二极管激光的证据强度非常低，PDT、臭氧和UAI研究的证据强度低。
纳入的研究在辅助治疗类型、每种辅助治疗的技术细节、结局报告以及这些因素的几种组合方面存在显著异质性，限制了荟萃分析的可能性。
没有足够的证据推荐任何辅助治疗用于根尖周炎的治疗。
Prospero CRD42021261869。
