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Kui J Pers Maja Da 201014954965
Kui J Pers Maja Da 201014954965
®
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N
ures can be caused by
CON
IO
review to assess whether there is a reduction of sali-
patient-related factors such as an
T
T
vation with the use of antisialogogues, whether the
A
N
I
inability to open the mouth prop- U
IN U
C
TABLE 1
face of the tooth is dry during bonding.1-5 ence uncontrollable drooling.6,7 For a short, tem-
Reductions in the time needed for dental pro- porary reduction of salivary flow, the remaining
cedures, bonding appliances and procedures per- options are either prescribing an antisialogogue
formed to maintain a dry working area can make (a drug that reduces, slows or prevents the flow of
the bonding procedure less cumbersome for the saliva) or temporarily blocking the main excretory
dental practitioner and the patient. Cotton rolls, ducts (for example, with cotton rolls). Antisialo-
saliva ejectors, soft-tissue and tongue retractors, gogues have been used in dentistry for many
and high vacuum suction can be used to help keep years to reduce salivary flow.8 They usually are
the operating field as dry as possible when administered one hour before bonding takes place
bonding brackets. However, if a dry operation or a submucosal injection is administered. The
field is required to bond brackets successfully and most common antisialogogues are antimuscarinic
to decrease the chair time for bonding, reducing and anticholinergic agents. Such agents have an
or even stopping salivary flow may be an option. effect on the central nervous system, but also on
There are several ways to block or reduce salivary
flow, including the use of botulinum toxin and the ABBREVIATION KEY. ADA: American Dental
injection and rerouting of the submandibular Association. GCF: Gingival crevicular fluid. IM:
ducts. These techniques, however, primarily are Intramuscular. IV: Intravenous. RCT: Randomized
long-lasting treatments for patients who experi- controlled trial.
Excluded studies N = 18
Reasons:
● Review article/expert opinion
Relevant studies
● Materials and methods not specified
N = 26
RCT RCT n = 10
N=1 Controlled trial n = 15
Figure. Quality of Reporting Meta-analyses flow chart of the literature selection process. ADA: American Dental Association.
RCT: Randomized controlled trial.
dental procedures) and question 3 (whether it Grading the methodological quality of the
reduces the failure rate of the bonded orthodontic studies and level of evidence. We evaluated
brackets). the studies according to a scoring system devel-
We used the broader inclusion criteria term oped by the Swedish Council on Technology
“dentistry” in addition to “orthodontics,” because Assessment in Health Care,16 which was based on
antisialogogues occasionally are used for the the criteria for assessing study quality from the
same purpose with other dental procedures. Centre for Reviews and Disseminations in York,
We excluded reviews and letters, and scored England.17 The quality grading criteria are listed
the abstracts as included, excluded or unclear in Table 2.16 We judged the final level of evidence
after reviewing the abstract only. We clarified dif- for the conclusion of each study according to the
ferences among ourselves by means of reaching a following scale.18
consensus. Then we retrieved the full texts of the dStrong scientific support (evidence grade 1).
included articles and articles with unclear Conclusion was based on at least two studies with
abstracts and searched the reference lists for quality grade A evidence. Studies with opposing
additional articles. We also searched the refer- conclusions may lower the evidence grade.
ence lists of review articles for additional articles. dModerately strong scientific support (evidence
We included and scored any of these additional grade 2). Conclusion based on one study with
articles that we thought might be of interest. strong evidence (quality grade A) and at least two
TABLE 3
Markkanen 18 Scopolamine 20 micrograms/ 30 minutes before, 0, 20, 40, 60, Reduction of nonstimulated and
and Pihlajamäki 21 hydrobromide kilogram body 90, 120, 150, 180, 240 and stimulated salivation, after 5
(1987) weight 300 minutes hours at premedication level
Wolff and 10 Glycopyrrolate 0.3 mg IM* Baseline, 0, 15, 60, 105 and 150 Reduction of salivation,
Kleinberg 22 minutes reduction of mucosal wetness,
(1999) no reduction of gingival
crevicular fluid
Brandt and 10 Atropine sulfate 0.4 mg/cubic 30 minutes preinjection, Initial increase, after 20 minutes
Colleagues 23 centimeter 5, 20, 35, 50, 65, 80, 95 and decrease, still below control
(1981) submucosal 110 minutes; 8, 12 and 22 hours 110 minutes, 8 hours salivation
injection above control
Dobkin and 5 Oxyphenonium 1 mg IV§ Baseline, 10-, 20- and 30-minute 95% saliva reduction
Colleagues 24 bromide intervals in week between drugs
(1958)
Methantheline 10 mg IV 96% saliva reduction
bromide
Promethazine 25 mg IV 93% saliva reduction
Chlorpromazine 20 mg IV 33% saliva reduction
Atropine 0.4 mg IV 83% saliva reduction
Hexocyclium 2 mg IV 97% saliva reduction
Herxheimer 25 12 Atropine sulfate 0.5 mg/70 kg, Patient received two to four Decreased salivation
(1958) 1.0 mg/70 kg, different doses, three days
2.0 mg/70 kg between each experiment;
baseline observations, time line
Methantheline 7.0 mg/70 kg, not clearly mentioned; every
bromide 14.0 mg/70 kg, hour until 6 hours after
28 mg/70 kg,
56 mg/70 kg
Propantheline 2.1 mg/70 kg,
bromide 4.2 mg/70 kg,
8.4 mg/70 kg,
16.8 mg/70 kg
TABLE 3
Mirakhur and 6 Atropine 0.5 mg, 1 mg, Baseline, 6 hours Dose-dependent reduction
Dundee 30 (1980) 2 mg IM observation of saliva secretion
More prolonged saliva reduction
Glycopyrrolate 0.1 mg, 0.2 mg, (5.6 times potency of atropine)
0.4 mg IM with glycopyrrolate
Wyant and Kao 31 12 Glycopyrrolate 0.1, 0.2 mg 5, 10, 20, 30 minutes, then Dose-dependent reduction
(1974) 2, 3, 4, 5, 7 and 10 hours of saliva secretion
Atropine 0.4 mg Prolonged effect with
glycopyrrolate
Brion and 8 Terfenadine 60 mg Baseline, 1, 3 and 7 hours after None
Colleagues 32 medication
(1988) Mequitazine 5 mg None
Atropine 1 mg Atropine produced drop in
saliva secretion
Kemmer and 8 Atropine 0.5 mg IV Before and three times Reduction in salivary secretion
Malfertheiner 33 after medication,
(1985) exact time line not clear
Volz-Zang and 7 Atropine 0.03 mg/kg oral 0, 30, 60, 90, 120, 150, 180 and Oral: 84.3% reduced saliva
Colleagues 34 0.02 mg/kg IM 210 minutes secretion maximal at 105 minutes
(1995) IM: 87.5% reduced secretion
maximal at 30 minutes
Rashid and 14 Atropine 0.3 mg IV 15, 30, 45, 60, 75 and 90 minutes Reduced salivary secretion;
Bateman 35 (1990) 0.6 mg IV effect greater in elderly people
TABLE 3
Arneberg and 14 Scopolamine 1.5 mg Before and 1, 2, 3 and Reduced salivary secretion,
Colleagues 38 transcutaneous 4 days after unstimulated secretion more
(1989) than stimulated secretion
Litta-Modignani 8 Scopolamine 2.5 mg, 5 mg IV 30, 15 minutes before and Reduction in salivary secretion
and Colleagues 39 2, 8, 32 and 64 minutes after within 2 minutes, baseline level
(1977) Hyoscine 10 mg, 20 mg IV medication again at 32 minutes
Mirakhur 41 (1978) 6 Atropine 0.5 mg, 1 mg, 2 30 minutes before Dose-dependent reduction of
mg oral or IM 30, 60 minutes, then salivary secretion and more
2, 3, 4, 5 and 6 hours pronounced with IM
Effect more pronounced with
hyoscine
Hyoscine 0.25 mg, 0.5 mg,
1 mg oral or IM
Grundhofer and 4 Propantheline 15 mg and 30 mg 30 minutes before and 0, 30, 60, Propantheline showed a greater
Gibaldi 42 (1977) 90, 120, 150, 180, 210, 240, 270, reduction in salivary secretion,
Hexocyclium 25 mg and 75 mg 300 and 360 minutes but not all data clear
Isopropamide 5 mg
Möller and 16 Atropine 2 mg, 4 mg oral; 30 and 15 minutes before; Dose-dependent reduction
Rosén 43 (1968) 0.33, 1 and 1, 2, 3, 4, 5, 6, 7 and 8 hours in salivary secretion for
3 mg IM after medication all medication
Methylscopolamine 4, 8, 16 mg oral;
0.16 and
0.5 mg IM
methantheline, propantheline and glycopyrrolate the patients had to take atropine before visiting
for dental procedures, and for orthodontic use in the orthodontist. Additionally, no distinction was
particular, remain unclear. Furthermore, the only made between patients with normal salivation and
RCT conducted on the effect of atropine on bond those with hypersalivation so that researchers
failure failed to show a significant effect.8 The could observe whether this distinction made a dif-
authors of the study, however, did not assess ference in bonding and whether there could be an
chair time when bonding and did not assess indication for people with hypersalivation to use
whether the presence of a dry field reduced the atropine. More studies are needed to support these
working time. Another limitation of the study was results8 to conclude whether antisialogogue use
that compliance was not well controlled, because has a place in dentistry.
TABLE 3 (CONTINUED) however, it has not been studied with the other
drugs used. Therefore, the questions remain
whether GCF does affect the bonding of brackets
and whether using an antisialogogue will reduce
REPORTED SIDE EFFECTS CONTROL QUALITY the secretion of GCF and achieve reductions in
GRADE
chair time and bond failure. These topics need
Not reported Placebo A
further study.
The adverse effects of several antisialogogues
Not reported Placebo; patient A were not properly studied in any of the studies we
was own con- included in our review; for example, ocular effects
trol
and effects on heart rate and blood pressure were
not always studied. This is a clinically relevant
Not reported Placebo; patient A omission, as pharmaceutical resources11,12 warn
was own com-
parison about atropine use in particular, owing to its
unpredictable individual response. Moreover,
Dose-related increase in heart Patient was own A
rate for 30 minutes; adaptation comparison adverse effects and intoxication effects from anti-
of pupil reduced sialogogue use are not dose dependent. These
give patients a medication without a true medical 15. Yagiela JA. Agents affecting salivation. In: ADA Guide to Dental
Therapeutics. 2nd ed. Ciancio SG, ed. Chicago: American Dental Asso-
indication simply to make the bonding procedure ciation; 2000:198-210.
easier or to prevent bracket failure, especially 16. Bondemark L, Holm AK, Hansen K, et al. Long-term stability of
orthodontic treatment and patient satisfaction: a systematic review.
when these medications can have lasting effects Angle Orthod 2007;77(1):181-191.
after the patient has left the office.11,21,23 17. Deeks J, Glanville J, Sheldon T. Undertaking Systematic Reviews
of Research on Effectiveness: CRD Guidance for Those Carrying Out or
Considering possible alternatives for medica- Commissioning Reviews. York, England: NHS Centre for Reviews and
tion, one might consider hypnosis or other Dissemination; 2001. CRD report no. 4.
18. Mohlin B, Axelsson S, Paulin G, et al. TMD in relation to maloc-
methods that would allow patients to sleep during clusion and orthodontic treatment. Angle Orthod 2007;77(3):542-548.
the procedure to take advantage of the fact that 19. Kazen DH, Dille JM. An evaluation of atropine as an antisialo-
gogue in dentistry. Oral Surg Oral Med Oral Pathol 1963;16:919-925.
there is a reduction in salivation during sleep.48 20. Lönnerholm G, Widerlöv E. Effect of intravenous atropine and
These alternatives, however, probably would not methylatropine on heart rate and secretion of saliva in men. Eur J Clin
Pharmacol 1975;8(3-4):233-240.
reduce chair time and all patients might not sleep 21. Markkanen YJ, Pihlajamäki K. Oral scopolamine hydrobromide
with their mouths open, leading to additional pro- solution as an antisialagogic agent in dentistry. Oral Surg Oral Med
Oral Pathol 1987;63(4):417-420.
cedures that might need to be performed to pre- 22. Wolff MS, Kleinberg I. The effect of ammonium glycopyrrolate
vent patients from closing their mouths. Another (Robinul)-induced xerostomia on oral mucosal wetness and flow of gin-
gival crevicular fluid in humans. Arch Oral Biol 1999;44(2):97-102.
solution that could be developed would be a 23. Brandt S, Servoss JM, Persily KB. Atropine sulphate: an effective
device that can easily stop salivation for a certain antisialogogue. J Clin Orthod 1981;15(9):629-634.
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