Top 5 Antibiotics Used in Dentistry and Their Indications

Antibiotics in dentistry have an important role in the management of selected odontogenic infections and in specific prophylactic situations.

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However, most localized pulpal and periapical conditions do not require systemic antibiotics when appropriate definitive dental treatment is available.

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Current evidence emphasizes source control through procedures such as drainage, pulpotomy, pulpectomy, or root canal treatment rather than routine antibiotic prescribing.
Antibiotics are primarily indicated when there is spreading infection, systemic involvement, significant risk of complications, or a specific prophylactic indication. Appropriate selection should consider the suspected microbiology, allergy history, drug interactions, antimicrobial spectrum, and local prescribing guidance.

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1. Amoxicillin
Amoxicillin is one of the most commonly used antibiotics in dental practice and is frequently preferred as a first-line agent when systemic antibiotic therapy is indicated for an odontogenic infection.
Its activity includes many of the aerobic and anaerobic organisms commonly associated with dental infections. The ADA guideline considers oral amoxicillin a preferred first-line option for immunocompetent adults requiring antibiotics for selected pulpal or periapical infections with systemic involvement.

Main indications include:
▪️ Odontogenic infection with systemic involvement
▪️ Spreading infection when systemic antibiotic therapy is indicated
▪️ Selected acute dental infections when definitive treatment cannot be immediately provided
Amoxicillin should not be prescribed simply for dental pain, irreversible pulpitis, or a localized infection that can be adequately managed with definitive dental treatment.

2. Penicillin V (Phenoxymethylpenicillin)
Penicillin V remains an important narrow-spectrum option for odontogenic infections. Its relatively narrow antimicrobial spectrum makes it attractive from an antibiotic-stewardship perspective.
Current Scottish Dental Clinical Effectiveness Programme (SDCEP) guidance identifies phenoxymethylpenicillin as the first-choice antibiotic for dental abscesses when antibiotic treatment is actually indicated.

Main indications include:
▪️ Dental abscess with spreading infection
▪️ Odontogenic infection accompanied by systemic involvement
▪️ Situations in which a narrow-spectrum penicillin is appropriate
Amoxicillin may be preferred in some settings because of dosing convenience and broader activity, but broader-spectrum therapy should not automatically be considered superior.

3. Metronidazole
Metronidazole has strong activity against anaerobic bacteria and has an important role in the management of odontogenic infections.
It may be used as an alternative in certain patients with penicillin allergy according to some prescribing guidelines, or as an adjunct to a penicillin-class antibiotic when there is severe or spreading infection and inadequate response to initial therapy.

Main indications include:
▪️ Odontogenic infections with a substantial anaerobic component
▪️ Selected dental abscesses in patients who cannot receive penicillin
▪️ Adjunctive treatment when severe or spreading infection requires broader anaerobic coverage
Its use should be based on the clinical presentation rather than routine combination therapy.

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4. Azithromycin
Azithromycin is a macrolide that can be considered in selected patients with a penicillin allergy, particularly when an oral alternative is required.
It also has a specific role in infective endocarditis prophylaxis for patients who meet current high-risk cardiac criteria and cannot receive a penicillin or ampicillin. The American Heart Association's 2021 scientific statement lists azithromycin among the oral alternatives for appropriate patients with penicillin or ampicillin allergy.

Main indications include:
▪️ Selected odontogenic infections in patients with appropriate penicillin allergy
▪️ Certain prophylactic indications for infective endocarditis when guideline criteria are fulfilled
Azithromycin should not be used routinely when a narrower and more appropriate first-line antibiotic is available.

5. Clindamycin
Clindamycin has historically been widely used in dentistry, particularly for patients reporting penicillin allergy. However, its contemporary role has become substantially more restricted.
The 2021 AHA scientific statement no longer recommends clindamycin for infective endocarditis prophylaxis because of its greater potential for severe adverse reactions, including Clostridioides difficile infection.
Current dental prescribing guidance also recommends restricting clindamycin to selected severe infections when first-line therapy has failed or specialist input is appropriate.

Potential indications include:
▪️ Selected severe odontogenic infections when first-line therapy is unsuccessful
▪️ Situations requiring specialist-directed alternative therapy
Therefore, clindamycin should not be considered a routine first-line antibiotic for dental infections or infective endocarditis prophylaxis.

✅ Clinical Comparison

Antibiotic	Primary Dental Role	Key Clinical Consideration
Amoxicillin	First-line treatment for selected odontogenic infections	Preferred by ADA when antibiotics are indicated in appropriate adult patients
Penicillin V	Dental abscess with spreading or systemic infection	Narrow spectrum supports antimicrobial stewardship
Metronidazole	Anaerobic coverage; alternative or adjunct in selected cases	Useful when anaerobic involvement is clinically relevant
Azithromycin	Selected infections or prophylaxis in penicillin-allergic patients	Not a routine substitute when first-line therapy is appropriate
Clindamycin	Restricted alternative for selected severe infections	Higher risk of serious adverse effects, including C. difficile infection

✅ When Are Antibiotics Actually Indicated in Dentistry?
The central principle is that antibiotics are adjuncts, not substitutes for definitive dental treatment.
For most immunocompetent adults with pulpal or periapical disease, the preferred approach is appropriate operative management. Antibiotics become more relevant when infection is associated with systemic manifestations, spreading cellulitis, significant diffuse swelling, lymphadenopathy, fever, malaise, or situations in which adequate source control cannot be immediately achieved.
The 2026 ADA antibiotic-stewardship statement reinforces the importance of limiting antibiotic use to situations in which the expected clinical benefit outweighs the potential harms.

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💬 Discussion
The selection of a dental antibiotic should not be based solely on familiarity or historical prescribing patterns. Contemporary evidence increasingly emphasizes antimicrobial stewardship, narrow-spectrum therapy when appropriate, short effective treatment courses, and reassessment of the clinical response.
Recent evidence also demonstrates that inappropriate prescribing remains a significant problem in dentistry. A 2025 systematic review found that dental antibiotic-stewardship interventions can improve prescribing practices, although the evidence base remains limited.
The distinction between therapeutic antibiotics and prophylactic antibiotics is also essential. Prophylaxis is indicated only for specific clinical circumstances, such as selected patients at highest risk of adverse outcomes from infective endocarditis. It should not be routinely prescribed solely because a patient has a prosthetic joint or because an invasive dental procedure is planned.

✍️ Conclusion
Amoxicillin, penicillin V, metronidazole, azithromycin, and clindamycin represent important antibiotics encountered in dental practice, but their clinical roles are not equivalent. Amoxicillin and penicillin V remain important first-line options when systemic antibiotic therapy is justified, whereas metronidazole provides valuable anaerobic coverage. Azithromycin has selected roles in penicillin-allergic patients, while clindamycin should now be reserved for limited circumstances because of its adverse-effect profile.
The most important prescribing principle is not identifying the strongest antibiotic, but determining whether an antibiotic is indicated at all and, when it is, selecting the narrowest appropriate agent for the shortest effective duration.

🎯 Clinical Recommendations
▪️ Do not prescribe antibiotics for uncomplicated dental pain or localized pulpal disease when definitive dental treatment can be provided.
▪️ Prioritize source control through drainage and appropriate endodontic, periodontal, or surgical treatment.
▪️ Use amoxicillin or penicillin V as appropriate first-line options when systemic antibiotic therapy is indicated.
▪️ Consider metronidazole when anaerobic coverage is clinically relevant or as an appropriate alternative/adjunct according to the clinical scenario.
▪️ Use azithromycin selectively in appropriate penicillin-allergic patients and for specific prophylactic indications.
▪️ Avoid routine clindamycin use, particularly for infective endocarditis prophylaxis.
▪️ Reassess patients receiving antibiotics when clinically appropriate and modify therapy if the diagnosis, response, or source control is inadequate.
▪️ Consult current national/local prescribing guidance for dose, duration, contraindications, drug interactions, pregnancy, pediatric dosing, and allergy-specific recommendations.

📚 References

✔ American Dental Association. (2026). Antibiotic stewardship: Balancing patient care and public health. American Dental Association.
✔ American Dental Association. (2019). Evidence-based clinical practice guideline on antibiotic use for the urgent management of pulpal- and periapical-related dental pain and intraoral swelling: A report from the American Dental Association. Journal of the American Dental Association, 150(11), 906–921.e12. https://doi.org/10.1016/j.adaj.2019.08.020
✔ American Dental Association. (2026). Antibiotic prophylaxis prior to dental procedures. American Dental Association.
✔ Bhuvaraghan, A., King, R., Walley, J., Thiruvenkatachari, B., & Aggarwal, V. R. (2024). Dental antibiotic policies, stewardship, and implementation in India: A policy document analysis. Community Dentistry and Oral Epidemiology, 52(6), 844–860. https://doi.org/10.1111/cdoe.12989
✔ Teoh, L., Löffler, C., Mun, M., Agnihotry, A., Kaur, H., Born, K., & Thompson, W. (2025). A systematic review of dental antibiotic stewardship interventions. Community Dentistry and Oral Epidemiology, 53(3), 245–255. https://doi.org/10.1111/cdoe.13009
✔ Vázquez-Cancela, O., Zapata-Cachafeiro, M., Herdeiro, M. T., Figueiras, A., & Rodríguez-Fernández, A. (2024). Dentists' knowledge, attitudes and perceptions of antibiotic prescribing: A systematic review. Preventive Medicine, 185, 108043. https://doi.org/10.1016/j.ypmed.2024.108043
✔ Wilson, W., Taubert, K. A., Gewitz, M., Lockhart, P. B., Baddour, L. M., Levison, M., et al. (2021). Prevention of viridans group streptococcal infective endocarditis: A scientific statement from the American Heart Association. Circulation, 143(20), e963–e978. https://doi.org/10.1161/CIR.0000000000000969

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When to Replant an Avulsed Permanent Tooth in Children

Avulsion of a permanent tooth is one of the most serious dental traumatic injuries in children and represents a true dental emergency.

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PDF 🔽 Reimplantation of avulsed dry permanent teeth after three days: A report of two cases ... When the tooth remains dry for an extended period, periodontal ligament cell necrosis is inevitable, significantly compromising long-term outcomes and increasing the risk of ankylosis and root resorption.

The prognosis is strongly influenced by the condition of the periodontal ligament (PDL) cells and the time elapsed between avulsion and replantation.

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Current International Association of Dental Traumatology (IADT) guidelines emphasize that prompt replantation should be the primary objective whenever a permanent tooth has been avulsed.
Importantly, delayed presentation does not automatically contraindicate replantation. The clinical decision depends principally on whether the tooth is permanent, the extraoral dry time, the storage conditions, and whether the apex is open or closed.

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✅ When Should an Avulsed Permanent Tooth Be Replanted?
An avulsed permanent tooth should generally be replanted as soon as possible, including when the extraoral dry time has exceeded 60 minutes. Replantation is intended to preserve the tooth, maintain alveolar bone, restore esthetics and function, and provide a temporary or potentially long-term solution during growth.
Primary teeth should never be replanted because of the risk of damaging the developing permanent successor.
The prognosis, however, changes substantially according to extraoral dry time:

Clinical situation	PDL prognosis	Replantation approach
Tooth replanted immediately or within a very short period	PDL cells may remain viable	Immediate replantation is strongly indicated.
Extraoral dry time <60 minutes, with appropriate storage	Some PDL viability may remain	Replant as soon as possible.
Extraoral dry time >60 minutes	PDL cells are expected to be non-viable	Replantation is still recommended, but long-term ankylosis and replacement resorption are expected.
Unknown or prolonged extraoral time	Prognosis is uncertain	Do not delay replantation solely because the prognosis is poor.

Adapted from current IADT recommendations for avulsed permanent teeth.

✅ How Does Apex Status Affect Replantation?

Permanent Teeth With an Open Apex
In children with an immature permanent tooth and an open apex, replantation should be performed promptly because preservation of the apical tissues may permit pulp revascularization.
Endodontic treatment should not automatically be performed immediately. Instead, the tooth should be monitored closely for evidence of pulp necrosis and infection. If necrosis and infection develop, appropriate endodontic treatment should be initiated.
This approach is particularly important in young patients because preservation of the tooth and alveolar bone can have substantial developmental and esthetic value.

Permanent Teeth With a Closed Apex
For a closed-apex permanent tooth, revascularization is unlikely. The tooth should nevertheless be replanted promptly because replantation remains the treatment of choice for an avulsed permanent tooth.
Root canal treatment is generally indicated after replantation according to the clinical situation and current trauma protocol, rather than delaying replantation while attempting to establish endodontic access.

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✅ Does a Dry Tooth for More Than 60 Minutes Need Replantation?
Yes. A prolonged dry time substantially worsens the periodontal prognosis, but it does not normally eliminate the indication for replantation.
When the total extraoral dry time exceeds approximately 60 minutes, the PDL is considered non-viable. Consequently, ankylosis and replacement resorption become major long-term concerns. Nevertheless, replantation can preserve the tooth temporarily, maintain alveolar bone dimensions, and provide esthetic and functional benefits during childhood and adolescence.
Therefore, a poor periodontal prognosis should not be interpreted as an indication to leave an avulsed permanent tooth out of the socket.

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✅ What Storage Conditions Matter?
If immediate replantation is not possible, the tooth should be placed in an appropriate storage medium to reduce damage to PDL cells.
Preferred options include Hank's Balanced Salt Solution (HBSS) or commercially available tooth-preservation solutions. Milk is also an acceptable readily available medium. Saline or saliva may be used when better alternatives are unavailable, although they provide less favorable conditions for prolonged storage.
The tooth should be handled by the crown rather than the root, and unnecessary manipulation or scraping of the root surface should be avoided.
The key objective is to minimize the period during which PDL cells are exposed to a dry environment.

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✅ Immediate Clinical Management
Once the patient reaches the dental office, management should include:

1. Confirm that the avulsed tooth is permanent.
2. Assess the medical history and associated facial or oral injuries.
3. Handle the tooth carefully by the crown.
4. Remove gross contamination by gentle irrigation when necessary.
5. Replant the tooth as soon as clinically possible.
6. Confirm its position clinically and radiographically.
7. Apply an appropriate flexible splint, generally for approximately 2 weeks.
8. Evaluate the need for systemic antibiotics according to the patient's age and clinical circumstances.
9. Verify tetanus immunization status and refer for medical assessment when indicated.
10. Establish structured clinical and radiographic follow-up.
The presence of associated alveolar or jaw fractures may require a modified stabilization period and management plan.

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💬 Discussion
The principal clinical error in avulsion injuries is allowing concern about prognosis to delay replantation. Extraoral dry time is one of the strongest prognostic determinants, but even when the PDL is considered non-viable, current IADT recommendations continue to favor replantation of permanent teeth in most pediatric patients.
The objective changes according to the biological circumstances. When PDL cells remain viable, treatment aims to preserve periodontal healing and reduce inflammatory complications. After prolonged dry storage, predictable periodontal healing is no longer expected; the purpose of replantation becomes primarily preservation of the tooth and surrounding alveolar structures, with recognition that replacement resorption and ankylosis may eventually compromise the tooth.
In immature teeth, the possibility of pulp revascularization provides an additional reason to replant promptly. In mature teeth, endodontic management is usually required because spontaneous revascularization is considerably less predictable.
Thus, replantation should be viewed as an urgent treatment decision rather than a procedure reserved only for teeth with a favorable prognosis.

🎯 Clinical Recommendations
▪️ Replant an avulsed permanent tooth as soon as possible, regardless of whether the extraoral dry time is short or prolonged.
▪️ Do not replant an avulsed primary tooth.
▪️ For an open-apex tooth, prioritize rapid replantation and monitor for possible revascularization.
▪️ For a closed-apex tooth, anticipate the need for endodontic management.
▪️ If dry time exceeds 60 minutes, explain that ankylosis and replacement resorption are likely, but this does not usually justify withholding replantation.
▪️ Use an appropriate storage medium whenever immediate replantation cannot be performed.
▪️ Ensure appropriate flexible splinting and long-term clinical/radiographic follow-up.

✍️ Conclusion
Replantation remains the treatment of choice for an avulsed permanent tooth in children. The decision should not be based solely on the elapsed time. Immediate replantation offers the best periodontal prognosis, whereas delayed replantation may still preserve important esthetic, functional, and alveolar benefits despite a substantially increased risk of ankylosis and replacement resorption. Open-apex teeth require particular attention because pulp revascularization may occur, while closed-apex teeth generally require endodontic management.

📚 References

✔ American Academy of Pediatric Dentistry. (2023). Acute management of an avulsed permanent tooth. In The reference manual of pediatric dentistry (pp. 680–681). American Academy of Pediatric Dentistry.
✔ Fouad, A. F., Abbott, P. V., Tsilingaridis, G., Cohenca, N., Lauridsen, E., Bourguignon, C., O'Connell, A., Flores, M. T., Day, P. F., Hicks, L., Andreasen, J. O., Cehreli, Z. C., Harlamb, S., Kahler, B., Oginni, A., Semper, M., & Levin, L. (2020). International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teeth. Dental Traumatology, 36(4), 331–342. https://doi.org/10.1111/edt.12573
✔ Levin, L., Day, P. F., Hicks, L., O'Connell, A., Fouad, A. F., Bourguignon, C., & Abbott, P. V. (2020). International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: General introduction. Dental Traumatology, 36(4), 309–313. https://doi.org/10.1111/edt.12574
✔ Bennett, R., Loo, Y., & Ilyas, N. (2021). IADT 2020 Guidelines: What should the dental professional know? Primary Dental Journal, 10(4), 95–99. https://doi.org/10.1177/20501684211066527

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Skeletal vs Dental Malocclusion: Key Differences and Treatment Planning

Skeletal and dental malocclusions may produce similar occlusal findings but require fundamentally different diagnostic approaches and treatment strategies.

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A Class II or Class III molar relationship, increased overjet, deep bite, or anterior crossbite does not by itself establish whether the primary problem originates from the jaws or the dentition.

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The distinction between skeletal discrepancy and dental compensation is particularly important when treatment may involve growth modification, orthodontic camouflage, temporary skeletal anchorage, or orthognathic surgery.
Accurate diagnosis therefore requires integration of facial examination, dental relationships, skeletal measurements, incisor inclination, and soft-tissue characteristics rather than reliance on a single cephalometric parameter.

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🔹 What Is a Dental Malocclusion?
A dental malocclusion primarily results from abnormal tooth position, inclination, rotation, crowding, spacing, or dental arch relationships despite relatively acceptable underlying skeletal relationships.

Examples include:
▪️ Dental crowding or spacing
▪️ Rotated or displaced teeth
▪️ Dental midline discrepancies
▪️ Dentoalveolar Class II or Class III relationships
▪️ Localized crossbites caused predominantly by tooth position
▪️ Incisor inclination abnormalities
In these situations, orthodontic tooth movement can often correct the malocclusion without substantially altering the underlying skeletal relationship.

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🔹 What Is a Skeletal Malocclusion?
A skeletal malocclusion results primarily from an anteroposterior, vertical, or transverse discrepancy between the maxilla, mandible, or both.

Common patterns include:
▪️ Skeletal Class II: mandibular deficiency, maxillary excess, or a combination
▪️ Skeletal Class III: mandibular excess, maxillary deficiency, or a combination
▪️ Vertical skeletal discrepancies: hyperdivergent or hypodivergent facial patterns, anterior open bite, or excessive lower anterior facial height
▪️ Transverse skeletal discrepancies: maxillary or mandibular basal arch-width discrepancies
▪️ Facial asymmetries involving the underlying skeletal structures
Importantly, the dental arches may partially compensate for the skeletal discrepancy, potentially making the underlying skeletal problem less obvious clinically.

Diagnostic Feature	Dental Malocclusion	Skeletal Malocclusion
Primary origin	Tooth position or dentoalveolar relationship	Maxillary or mandibular skeletal discrepancy
Facial profile	Usually relatively balanced	May show sagittal, vertical, or transverse disharmony
Incisor position	Abnormal position may be the primary problem	Frequently compensatory to the skeletal discrepancy
Occlusal relationship	Often localized or primarily dentoalveolar	Often reflects a broader jaw discrepancy
Cephalometric findings	Skeletal bases may be relatively balanced	Sagittal, vertical, or transverse skeletal discrepancy may be evident
Treatment	Primarily orthodontic tooth movement	Growth modification, orthodontic camouflage, or orthognathic treatment depending on severity and growth status
Main limitation	Biological limits of dental movement	Biological limits of dental compensation

🔹 How to Differentiate Skeletal and Dental Components

1. Evaluate the Facial Pattern
Extraoral examination should precede interpretation of individual dental relationships. Assessment should include:

▪️ Facial symmetry
▪️ Profile convexity or concavity
▪️ Lower anterior facial height
▪️ Lip competence and incisor display
▪️ Chin projection
▪️ Vertical proportions
▪️ Smile and soft-tissue balance
Soft-tissue evaluation is particularly relevant because a technically acceptable occlusion may still be associated with an unfavorable facial profile when a significant skeletal discrepancy remains untreated.

2. Analyze the Dental Compensation
Incisor inclination is a critical diagnostic clue. In skeletal Class II and Class III patterns, the incisors may compensate for the underlying jaw discrepancy.

For example, a patient with skeletal Class III may present with:
▪️ Proclined maxillary incisors
▪️ Retroclined mandibular incisors
▪️ Relatively acceptable overjet despite a significant skeletal discrepancy
These compensations can mask the true severity of the skeletal problem. Conversely, removing the compensations during presurgical orthodontics may temporarily make the malocclusion appear worse while revealing the actual skeletal discrepancy.

3. Use Cephalometric Analysis as Part of the Diagnosis
Cephalometric analysis can help quantify the relationship between the maxilla, mandible, and dentition. Depending on the clinical problem, useful parameters may include:

▪️ SNA and SNB
▪️ ANB
▪️ Wits appraisal
▪️ Mandibular plane measurements
▪️ Upper and lower incisor inclinations
▪️ Interincisal angle
▪️ Vertical facial proportions
However, these measurements should not be interpreted independently. Reference planes, facial morphology, dental compensation, and individual anatomical variation can influence their diagnostic meaning.
Evidence also indicates that cephalometric radiographs are not universally necessary for every orthodontic patient; their value increases when a skeletal discrepancy, asymmetry, significant vertical problem, or potential surgical treatment requires clarification.

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🔹 Treatment Planning: Dental vs Skeletal Problems
Treatment planning should begin by determining where the discrepancy originates and what the biological limits of correction are.

1. Dental Malocclusion
When the skeletal bases are reasonably harmonious, treatment may focus on:
▪️ Alignment and leveling
▪️ Space management
▪️ Arch coordination
▪️ Incisor inclination
▪️ Correction of rotations
▪️ Interarch dental relationships
The treatment objective is primarily to establish a stable and functional dentition within the existing skeletal framework.

2. Skeletal Malocclusion
When the discrepancy is skeletal, treatment options depend on age, growth potential, severity, facial aesthetics, periodontal limitations, and patient-specific objectives.

Possible approaches include:
Growing patients
▪️ Growth modification when appropriate
▪️ Orthodontic correction of associated dental compensation
▪️ Dentofacial orthopedic approaches for selected sagittal or transverse discrepancies

Non-growing patients
▪️ Orthodontic camouflage for carefully selected mild-to-moderate discrepancies
▪️ Temporary skeletal anchorage when additional dentoalveolar control is required
▪️ Orthodontic-orthognathic treatment when the skeletal discrepancy exceeds the limits of dental compensation
Orthodontic camouflage can be effective in selected borderline cases, but it does not correct the underlying jaw discrepancy. Recent evidence continues to emphasize that treatment selection must consider the magnitude of the skeletal discrepancy, dental compensation, facial aesthetics, function, and the patient's treatment objectives.

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🔹 When Is Orthognathic Surgery Considered?
Orthognathic surgery becomes relevant when the skeletal discrepancy cannot be predictably corrected by orthodontic tooth movement without unacceptable dental, periodontal, functional, or facial consequences.

Important considerations include:
▪️ Magnitude of the skeletal discrepancy
▪️ Facial profile and soft-tissue imbalance
▪️ Incisor position relative to the basal bone
▪️ Available periodontal envelope
▪️ Vertical and transverse skeletal discrepancies
▪️ Stability of potential dental compensation
▪️ Growth status
▪️ Functional limitations
▪️ Patient expectations
In surgical cases, presurgical orthodontics is generally directed toward decompensating the dentition and positioning the teeth appropriately relative to their skeletal bases, allowing the surgical correction to address the underlying jaw discrepancy.

🔹 Skeletal vs Dental Malocclusion: A Practical Diagnostic Framework

Diagnostic Question	Clinical Interpretation	Treatment Implication
Are the maxillary and mandibular bases reasonably coordinated?	Suggests a predominantly dental problem.	Orthodontic tooth movement may be sufficient.
Is there a significant facial skeletal discrepancy?	Suggests a skeletal component.	Assess growth modification, camouflage, or surgery.
Are incisors markedly compensated?	Dental compensation may be masking the skeletal discrepancy.	Evaluate periodontal limits and potential for decompensation.
Can the discrepancy be corrected within the dental envelope?	Determines the feasibility of orthodontic compensation.	If limits are exceeded, surgical correction should be evaluated.

💬 Discussion
The distinction between skeletal and dental malocclusion is not simply a classification exercise; it determines the biological and therapeutic boundaries of orthodontic treatment. Dental compensation can produce an acceptable occlusal relationship while concealing a clinically important skeletal discrepancy.
This is particularly relevant in borderline Class II and Class III cases. Systematic reviews indicate that camouflage and surgical treatment produce different dentoskeletal effects, with surgery providing greater correction of the underlying skeletal relationship, whereas camouflage relies primarily on dental compensation.
Recent evidence also reinforces that there is no single numerical cephalometric threshold that independently determines treatment modality. Contemporary treatment planning should integrate skeletal measurements with facial aesthetics, dental compensation, periodontal boundaries, function, growth status, and the feasibility of achieving stable results.

✍️ Conclusion
Skeletal vs dental malocclusion should be differentiated through an integrated assessment of facial morphology, dental relationships, skeletal bases, incisor compensation, and soft tissues. A dental discrepancy may often be corrected through conventional orthodontic mechanics, whereas a significant skeletal discrepancy may require growth modification, carefully controlled camouflage, or orthognathic surgery.
The central treatment-planning principle is to determine whether the observed occlusion represents a primary dental problem or a dental compensation masking an underlying skeletal discrepancy.

💡 Clinical Pearls
▪️ Do not diagnose a skeletal discrepancy from molar or canine relationships alone.
▪️ Assess incisor inclination before deciding whether a Class II or Class III relationship is primarily dental or skeletal.
▪️ Interpret ANB, Wits, and other cephalometric measurements as components of a diagnostic system, not isolated treatment determinants.
▪️ Evaluate the facial profile and vertical proportions before selecting orthodontic camouflage.
▪️ When dental compensation approaches its biological limits, orthognathic evaluation should be considered rather than forcing further tooth movement.
▪️ In surgical cases, presurgical decompensation is intended to expose and facilitate correction of the true skeletal discrepancy, not to improve the occlusion before surgery.

📚 References

✔ Alhammadi, M. S., Almashraqi, A. A., Khadhi, A. H., Arishi, K. A., Alamir, A. A., Beleges, E. M., & Halboub, E. (2022). Orthodontic camouflage versus orthodontic-orthognathic surgical treatment in borderline class III malocclusion: A systematic review. Clinical Oral Investigations, 26(11), 6443–6455. https://doi.org/10.1007/s00784-022-04685-6
✔ Benyaia, H., Azaroual, M. F., Garcia, C., Hamou, E., Abouqal, R., & Zaoui, F. (2011). Treatment of skeletal Class III malocclusions: Orthognathic surgery or orthodontic camouflage? How to decide. International Orthodontics, 9(2), 196–209. https://doi.org/10.1016/j.ortho.2011.03.005
✔ Raposo, R., Peleteiro, B., Paço, M., & Pinho, T. (2018). Orthodontic camouflage versus orthodontic-orthognathic surgical treatment in Class II malocclusion: A systematic review and meta-analysis. International Journal of Oral and Maxillofacial Surgery, 47(4), 445–455. https://doi.org/10.1016/j.ijom.2017.09.003
✔ Sailer, H. F., & Prantl, F. A. (1999). Soft tissue cephalometric analysis: Diagnosis and treatment planning of dentofacial deformity. American Journal of Orthodontics and Dentofacial Orthopedics, 115(2), 224–232. https://doi.org/10.1016/S0889-5406(99)70345-8
✔ Sabri, R. (2006). Orthodontic objectives in orthognathic surgery: State of the art today. World Journal of Orthodontics, 7(2), 177–191.
✔ Stellzig-Eisenhauer, A., Lux, C. J., & Schuster, G. (2002). Treatment decision in adult patients with Class III malocclusion: Orthodontic camouflage versus orthognathic surgery. Journal of Orofacial Orthopedics, 63, 107–120.
✔ The British Association of Oral and Maxillofacial Surgeons. (2025). What are the limits of orthodontic treatment before surgical intervention is required? British Journal of Oral and Maxillofacial Surgery. https://doi.org/10.1016/j.bjoms.2025.07.008

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Minimally Invasive Pulpotomy in Symptomatic Teeth: Is It Possible?

Vital pulp therapy (VPT) has undergone a significant change in recent years. Historically, teeth with symptoms traditionally diagnosed as irreversible pulpitis were generally treated with root canal treatment or extraction.

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Current evidence indicates that selected mature permanent teeth with symptomatic pulpitis may retain sufficient reparative potential to be managed with pulpotomy.

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However, minimally invasive pulpotomy should not be regarded as a single standardized technique. The term is better understood as a tissue-preserving therapeutic approach in which the amount of pulp removed is limited to the tissue considered clinically compromised, while maintaining the vitality of the remaining pulp.
This distinction is important because Cvek partial pulpotomy represents a specific historical technique for partial removal of exposed coronal pulp, particularly in traumatic pulp exposures, whereas contemporary pulpotomy protocols have expanded into the management of cariously exposed mature permanent teeth with symptoms indicative of irreversible pulpitis.

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✅ What Is Minimally Invasive Pulpotomy?
A minimally invasive approach to pulpotomy aims to preserve the maximum amount of viable pulp compatible with effective removal of inflamed tissue and achievement of hemostasis.
The amount of tissue removed is therefore not determined exclusively by a predefined depth. Instead, it may be adjusted according to the clinical condition of the pulp after exposure.
Three concepts should be distinguished:

Procedure	Main Characteristic	Typical Clinical Context
Cvek partial pulpotomy	Limited removal of superficial exposed pulp, historically involving approximately 1–2 mm of tissue.	Traumatic pulp exposure, particularly in permanent incisors.
Contemporary partial pulpotomy	Removal of a limited amount of coronal pulp according to tissue condition and the ability to achieve hemostasis.	Selected carious pulp exposures, including mature teeth with symptomatic pulpitis.
Full pulpotomy	Removal of the entire coronal pulp to the level of the canal orifices while preserving the radicular pulp.	Mature teeth in which more extensive coronal pulp removal is required.

The Cvek technique should therefore not be used synonymously with minimally invasive pulpotomy. Its historical evidence base is primarily associated with traumatic pulp exposures, whereas contemporary partial pulpotomy has been investigated in mature permanent teeth with carious exposure and symptomatic pulpitis.

✅ Can Symptomatic Teeth Be Treated With a Minimally Invasive Approach?
Yes, in selected cases.
The current evidence challenges the assumption that symptoms traditionally associated with irreversible pulpitis automatically indicate complete loss of pulpal healing potential. The AAE recognizes that VPT may be considered in appropriately selected mature teeth previously diagnosed with irreversible pulpitis and emphasizes direct assessment of the exposed pulp as an important component of case selection.
A 2024 systematic review and meta-analysis found favorable outcomes for pulpotomy in mature permanent teeth diagnosed with irreversible pulpitis, although the authors emphasized limitations in the available evidence and heterogeneity among studies.
Importantly, the evidence does not mean that every symptomatic tooth is a candidate for partial pulpotomy. Rather, pulpal status must be reassessed after exposure and tissue removal.

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✅ Partial Pulpotomy in Symptomatic Mature Teeth
Contemporary randomized clinical trials provide increasing evidence supporting partial pulpotomy in selected mature permanent teeth with symptoms indicative of irreversible pulpitis.
In a randomized trial involving 50 mature molars, partial pulpotomy using Biodentine achieved an 88% success rate at 12 months, compared with 91.6% for full pulpotomy, with no statistically significant difference between groups.
Another randomized trial involving 106 mature mandibular molars reported 80.8% success for partial pulpotomy and 89.8% for complete pulpotomy at 12 months. Although the numerical difference favored complete pulpotomy, it was not statistically significant. The authors concluded that partial pulpotomy may be attempted because of its more conservative nature.
More recent research has also investigated how much pulp should be removed during partial pulpotomy. A 2025 randomized clinical trial compared restricted partial pulpotomy, in which approximately 2–3 mm of superficial pulp was removed only at the exposure site, with an extended approach involving removal of 2–3 mm of superficial pulp throughout the pulp chamber. This reflects the continuing shift toward determining the extent of tissue removal according to biological rather than purely mechanical criteria.

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✅ Clinical Determinants of Success
The key issue is not simply how little pulp can be removed, but whether the remaining pulp is capable of healing.

Clinical Factor	Importance in Treatment Selection
Preoperative diagnosis	Establishes the initial pulpal and periapical diagnosis but cannot determine the exact histological extent of inflammation.
Direct pulp assessment	Provides additional information after pulp exposure and removal of clinically compromised tissue.
Hemostasis	Controlled bleeding after pulp amputation supports proceeding with vital pulp therapy; persistent bleeding requires reassessment.
Aseptic isolation	Reduces microbial contamination of the exposed pulp and treatment field.
Extent of inflammation	Helps determine whether a limited partial pulpotomy or more extensive coronal pulp removal is appropriate.
Biomaterial	Calcium silicate-based hydraulic cements are widely used in contemporary vital pulp therapy.
Coronal seal	An effective definitive restoration is essential to prevent bacterial leakage and protect the treated pulp.

In randomized clinical studies, inability to control bleeding within a predefined period has been used as a criterion for abandoning the planned pulpotomy protocol. For example, one trial required hemostasis within six minutes before proceeding with treatment.
However, hemostasis time should not be interpreted as an absolute biological threshold. It is a clinical decision aid rather than a direct histological measurement of pulpal inflammation.

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✅ A Contemporary Minimally Invasive Protocol
A tissue-preserving approach should follow a biologically guided sequence:

1. Establish the pulpal and periapical diagnosis.
2. Obtain appropriate preoperative radiographs.
3. Achieve rubber dam isolation and aseptic control.
4. Remove infected dentin and expose the pulp when indicated.
5. Remove the clinically compromised coronal pulp.
6. Assess the remaining tissue and establish hemostasis.
7. Determine whether partial or full pulpotomy provides the most appropriate level of tissue removal.
8. Apply an appropriate calcium silicate-based biomaterial.
9. Provide a durable definitive coronal restoration.
10. Perform clinical and radiographic follow-up.
This approach is consistent with the contemporary VPT concept that direct visualization of pulp tissue after exposure can contribute to treatment selection, because conventional sensibility testing cannot establish the histological status of the pulp with sufficient precision.

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✅ Is the Cvek Technique the Same Procedure?
No.
The Cvek partial pulpotomy is a specific form of partial pulpotomy historically associated with traumatic crown fractures and exposed vital pulp, particularly in permanent incisors. The classic procedure involved removal of a small superficial portion of exposed pulp followed by placement of a pulp-capping material.
Long-term clinical studies have demonstrated favorable outcomes for partial pulpotomy in traumatized permanent incisors.
Contemporary partial pulpotomy for symptomatic carious teeth is conceptually related because both procedures preserve vital pulp tissue. However, they should not be treated as identical techniques because their indications, clinical circumstances, and evidence bases differ.

Thus:
Cvek partial pulpotomy = a specific partial pulpotomy technique.
Minimally invasive pulpotomy = a broader tissue-preservation approach that may involve partial or, when clinically necessary, full pulpotomy.

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💬 Discussion
The most important change in contemporary VPT is not the introduction of a new pulpotomy technique, but the recognition that pulpal inflammation is biologically heterogeneous. Clinical symptoms alone cannot reliably determine whether all remaining pulp tissue has lost its capacity for healing.
Consequently, a diagnosis such as symptomatic irreversible pulpitis should not automatically be interpreted as evidence that every portion of the pulp is irreversibly damaged. The AAE and contemporary evidence support combining preoperative diagnosis with direct intraoperative assessment when VPT is being considered.
The evidence supporting partial pulpotomy is particularly relevant to the minimally invasive concept. Randomized trials have demonstrated favorable short-term outcomes and, in several studies, no statistically significant difference between partial and full pulpotomy.
Nevertheless, the current evidence does not justify assuming that partial pulpotomy is universally superior. Some studies report numerically higher success with full pulpotomy, while follow-up periods remain relatively short in much of the literature. A 2024 meta-analysis likewise concluded that the evidence is promising but affected by heterogeneity and methodological limitations.
Therefore, the objective of minimally invasive pulpotomy should not be “remove as little pulp as possible”. The biologically appropriate objective is to remove compromised tissue while preserving the greatest amount of healthy, functional pulp that can predictably remain viable.

✍️ Conclusion
Minimally invasive pulpotomy is a valid contemporary concept within vital pulp therapy, but it is not synonymous with the Cvek technique.
The Cvek procedure is a specific form of partial pulpotomy historically used for traumatic pulp exposures. Contemporary minimally invasive pulpotomy encompasses a broader tissue-preserving philosophy that may involve partial or full pulpotomy according to the clinical condition of the pulp.
In selected mature permanent teeth with symptoms indicative of irreversible pulpitis, current evidence supports pulpotomy as a potential alternative to root canal treatment. However, successful treatment depends on appropriate case selection, asepsis, direct pulp assessment, effective hemostasis, suitable biomaterials, and a reliable coronal seal.

🎯 Clinical Recommendations
▪️ Do not use Cvek partial pulpotomy and minimally invasive pulpotomy as interchangeable terms.
▪️ Consider contemporary partial pulpotomy in selected symptomatic mature teeth when the remaining pulp demonstrates favorable clinical characteristics after tissue removal.
▪️ Do not impose a predetermined depth of tissue removal when the clinical condition of the pulp indicates that additional removal is necessary.
▪️ Use hemostasis and direct pulp assessment as important intraoperative decision points rather than relying exclusively on the preoperative diagnosis.
▪️ If a limited partial pulpotomy does not provide a suitable pulpal wound or controlled hemostasis, progress to a more extensive pulpotomy or reconsider VPT, according to the clinical circumstances.
▪️ Consider long-term follow-up essential because short-term symptom resolution does not by itself demonstrate sustained pulp vitality.

📚 References

✔ American Association of Endodontists. (2021). AAE position statement on vital pulp therapy. American Association of Endodontists.
✔ Duncan, H. F., Kirkevang, L.-L., Peters, O. A., El-Karim, I., Krastl, G., Del Fabbro, M., Chong, B. S., Galler, K. M., Segura-Egea, J. J., & Kebschull, M. (2023). Treatment of pulpal and apical disease: The European Society of Endodontology S3-level clinical practice guideline. International Endodontic Journal, 56(Suppl. 3), 238–295. https://doi.org/10.1111/iej.13974
✔ Jassal, A., Nawal, R. R., Yadav, S., Talwar, S., Yadav, S., & Duncan, H. F. (2023). Outcome of partial and full pulpotomy in cariously exposed mature molars with symptoms indicative of irreversible pulpitis: A randomized controlled trial. International Endodontic Journal, 56(3), 331–344. https://doi.org/10.1111/iej.13872
✔ Li, Y., Wang, W., Zeng, Q., Tang, M., Massey, J., Bergeron, B. E., Gu, L., & Tay, F. R. (2024). Efficacy of pulpotomy in managing irreversible pulpitis in mature permanent teeth: A systematic review and meta-analysis. Journal of Dentistry, 144, 104923. https://doi.org/10.1016/j.jdent.2024.104923
✔ Ramani, A., Sangwan, P., Tewari, S., Duhan, J., Mittal, S., & Kumar, V. (2022). Comparative evaluation of complete and partial pulpotomy in mature permanent teeth with symptomatic irreversible pulpitis: A randomized clinical trial. International Endodontic Journal, 55(5), 430–440. https://doi.org/10.1111/iej.13714
✔ Ramani, A., Sangwan, P., Tewari, S., Duhan, J., Mittal, S., & Kumar, V. (2025). Effect of lateral extent of pulp tissue removal on the outcome of partial pulpotomy for managing cariously exposed mature permanent molars with symptomatic irreversible pulpitis: A randomized clinical trial. International Endodontic Journal, 58(1), 71–83. https://doi.org/10.1111/iej.14152
✔ Tzanetakis, G. N., Koletsi, D., & Georgopoulou, M. (2023). Treatment outcome of partial pulpotomy using two different calcium silicate materials in mature permanent teeth with symptoms of irreversible pulpitis: A randomized clinical trial. International Endodontic Journal, 56(10), 1178–1196. https://doi.org/10.1111/iej.13955

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How Diabetes Increases the Risk of Oral Infections

Diabetes mellitus can substantially modify the oral environment and increase susceptibility to several oral infections and inflammatory diseases, particularly when glycemic control is poor.

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Hyperglycemia affects immune function, vascular physiology, inflammatory signaling, salivary function, and tissue repair, creating conditions that may facilitate microbial dysbiosis and prolong inflammation.

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The strongest evidence concerns the relationship between diabetes and periodontitis, which is now recognized as bidirectional. Contemporary longitudinal evidence also supports an association between diabetes and subsequent periodontal disease, although the magnitude of this association varies among studies.

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✅ How Does Diabetes Increase the Risk of Oral Infections?
Several biological mechanisms contribute to increased susceptibility.

1. Impaired Host Immune Response
Persistent hyperglycemia can alter innate immune-cell function, including neutrophil chemotaxis, adhesion, and phagocytic activity. This may reduce the efficiency with which the host controls pathogenic microorganisms within the oral biofilm.
At the same time, diabetes can promote a disproportionate inflammatory response to microbial challenge. The resulting imbalance between microbial control and inflammation is particularly important in periodontal tissues.

2. Hyperglycemia, AGEs, and Chronic Inflammation
Chronic hyperglycemia promotes the formation and accumulation of advanced glycation end products (AGEs). Interaction between AGEs and their receptor, RAGE, can increase oxidative stress and pro-inflammatory signaling.
In periodontal tissues, these mechanisms amplify the inflammatory response to the subgingival biofilm and contribute to connective-tissue and alveolar bone destruction.

3. Altered Salivary Function
Diabetes may be associated with reduced salivary flow, lower salivary pH, and reduced buffering capacity. A 2024 systematic review and meta-analysis found significant reductions in these salivary parameters among adults with type 2 diabetes, together with a higher DMFT index compared with non-diabetic individuals.
Reduced salivary protection can facilitate dental caries, particularly when combined with dietary factors, inadequate plaque control, or other xerogenic conditions.

4. Increased Periodontal Susceptibility
Periodontitis is the oral condition most consistently associated with diabetes. Diabetes is considered an important modifying factor for periodontal disease, and poor glycemic control is associated with greater periodontal severity and progression.
The relationship is bidirectional: periodontal inflammation can contribute to systemic inflammatory burden and adversely affect glycemic control. A 2026 systematic review and meta-analysis of 28 longitudinal studies involving more than 300,000 participants found evidence of temporal associations in both directions between diabetes and periodontitis.

5. Oral Candidiasis and Other Opportunistic Conditions
Oral candidiasis has been associated with diabetes, particularly in the presence of poor glycemic control, xerostomia, denture use, or other local risk factors. However, the strength of evidence is not equivalent to that observed for periodontitis.
A systematic review and meta-analysis found no statistically significant overall increase in oral candidiasis among diabetic patients, although denture stomatitis was more common in diabetic individuals. The certainty of this evidence was considered very low.
Therefore, diabetes should be considered a predisposing or modifying factor, rather than an independent explanation for every oral fungal infection.

✅ Main Oral Conditions Associated With Diabetes

Oral condition	Relationship with diabetes	Relevant mechanisms
Periodontitis	Strong and well-established association	Immune dysregulation, hyperglycemia, AGEs/RAGE, oxidative stress, exaggerated inflammation
Dental caries	Increased risk may occur, particularly in some diabetic populations	Reduced salivary flow, lower pH and buffering capacity, dietary and plaque-related factors
Oral candidiasis	Possible association; evidence is less consistent	Altered host defense, hyperglycemia, xerostomia and local factors
Denture stomatitis	Higher risk reported in diabetic patients	Candida-related biofilm, denture factors and altered host response

✅ Clinical Assessment
For dental professionals, glycemic control should be considered when assessing infection risk and treatment prognosis. A comprehensive history should include diabetes type, current medications, recent glycemic status when available, diabetes-related complications, and previous episodes of hypoglycemia or poor healing.
The American Diabetes Association Standards of Care 2026 recommends at least annual dental examination for people with diabetes and emphasizes coordination between medical and dental teams. Dental assessment should include periodontal evaluation and consideration of oral complications associated with diabetes.

Clinicians should pay particular attention to:
▪️ Bleeding on probing, periodontal pocketing, attachment loss, and tooth mobility
▪️ Recurrent or persistent oral infections
▪️ Xerostomia or symptoms suggesting salivary hypofunction
▪️ Root and coronal caries
▪️ Oral candidiasis and denture-associated inflammation
▪️ Delayed healing after invasive procedures
▪️ Evidence of inadequate glycemic control when clinically relevant

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💬 Discussion
The increased risk of oral disease in diabetes is not explained simply by the presence of elevated glucose in the oral cavity. Rather, hyperglycemia modifies the host–microbiome interaction, alters immune and inflammatory responses, and may compromise salivary protection and tissue repair.
Among oral conditions, periodontitis has the strongest and most clinically relevant evidence base. The association is also bidirectional: diabetes increases periodontal susceptibility, while periodontal inflammation may adversely influence glycemic control. The 2018 EFP/IDF consensus reported that periodontal therapy is safe in patients with diabetes and may produce modest reductions in HbA1c, although the long-term metabolic effect remains less certain.
Evidence for caries and salivary dysfunction has strengthened in recent years, with 2024 meta-analytic data demonstrating altered salivary parameters and higher caries experience in adults with type 2 diabetes. In contrast, evidence regarding oral candidiasis is less consistent and should be interpreted in the context of additional local and systemic risk factors.
Consequently, oral infection prevention should be incorporated into diabetes care rather than treated as an isolated dental issue.

✍️ Conclusion
Diabetes increases susceptibility to oral disease primarily through altered immune function, chronic inflammation, hyperglycemia-related tissue changes, salivary dysfunction, and impaired healing. The most firmly established association is with periodontitis, but caries, xerostomia-related complications, and selected fungal conditions may also be clinically relevant.
Effective management requires glycemic control, periodontal prevention and treatment, individualized caries prevention, appropriate oral hygiene, and coordination between dental and medical professionals.

🎯 Clinical Recommendations
1. Perform at least an annual comprehensive dental and periodontal examination in patients with diabetes, with shorter recall intervals when periodontal disease or other risk factors are present.
2. Consider glycemic status when evaluating periodontal prognosis, infection recurrence, and healing, particularly in patients with poorly controlled diabetes.
3. Prioritize periodontal prevention and treatment, because periodontitis represents the most consistently established oral complication associated with diabetes.
4. Assess salivary function and caries risk when xerostomia, recurrent caries, or root-surface lesions are present.
5. Investigate recurrent candidiasis or denture stomatitis for additional predisposing factors, rather than attributing the condition exclusively to diabetes.
6. Coordinate dental and medical care when glycemic control is inadequate or invasive treatment requires consideration of the patient's diabetes medications and hypoglycemia risk.

📚 References

✔ Botelho, J., Singh, S., Varenne, B., Rendell, N., Harada, Y., Proença, L., Machado, V., & Bitencourt, F. V. (2026). Oral health and diabetes: A systematic review and meta-analysis. The Lancet Public Health, 11(8), e555–e566. https://doi.org/10.1016/S2468-2667(26)00149-0
✔ Chapple, I. L. C., & Genco, R. (2013). Diabetes and periodontal diseases: Consensus report of the Joint EFP/AAP Workshop on Periodontitis and Systemic Diseases. Journal of Clinical Periodontology, 40(Suppl. 14), S106–S112. https://doi.org/10.1111/jcpe.12077
✔ Martorano-Fernandes, L., Dornelas-Filho, A. P., de Faria, R. L., & others. (2020). Oral candidiasis and denture stomatitis in diabetic patients: Systematic review and meta-analysis. Brazilian Oral Research, 34, e113. https://doi.org/10.1590/1807-3107bor-2020.vol34.0113
✔ Sanz, M., Ceriello, A., Buysschaert, M., Chapple, I., Demmer, R. T., Graziani, F., Herrera, D., Jepsen, S., Lione, L., Madianos, P., Mathur, M., Montanya, E., Shapira, L., Tonetti, M., & Vegh, D. (2018). Scientific evidence on the links between periodontal diseases and diabetes: Consensus report and guidelines of the joint workshop on periodontal diseases and diabetes by the International Diabetes Federation and the European Federation of Periodontology. Journal of Clinical Periodontology, 45(2), 138–149. https://doi.org/10.1111/jcpe.12808
✔ Zhou, G., Shu, X., Long, Y., Cao, Y., Wang, J., Liao, G., & Zou, L. (2024). Dental caries and salivary alterations in patients with type 2 diabetes: A systematic review and meta-analysis. Journal of Dentistry, 150, 105321. https://doi.org/10.1016/j.jdent.2024.105321

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