Dental Antibiotics: First-Line vs Alternative Options

The appropriate selection of dental antibiotics requires more than identifying a familiar antimicrobial agent. Current evidence emphasizes antibiotic stewardship, source control, accurate diagnosis, and the use of the narrowest effective antibiotic when systemic therapy is indicated.

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For most localized pulpal and periapical conditions in immunocompetent adults, definitive dental treatment remains the primary intervention. Antibiotics should generally be reserved for infections with systemic involvement, spreading infection, or selected situations in which immediate definitive treatment is not feasible.

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When antibiotics are indicated, first-line agents should generally be preferred over broader-spectrum alternatives. The choice of an alternative depends on treatment response, allergy history, infection severity, drug interactions, and local prescribing recommendations.

✅ When Are Dental Antibiotics Indicated?
Antibiotics are not routinely indicated for conditions such as symptomatic irreversible pulpitis or symptomatic apical periodontitis without evidence of spreading infection or systemic involvement. Appropriate treatment should instead focus on pulpotomy, pulpectomy, root canal treatment, drainage, or extraction when indicated.

Systemic antibiotic therapy may be considered when there is:
▪️ Fever or malaise
▪️ Spreading infection or cellulitis
▪️ Progressive swelling
▪️ Systemic involvement associated with an odontogenic infection
▪️ A significant risk of progression in a patient for whom definitive dental treatment is temporarily unavailable
Antibiotics should not substitute for source control. Definitive dental treatment should be arranged as soon as possible.

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✅ First-Line Dental Antibiotics
For an adult patient in whom systemic antibiotic therapy is clinically indicated, amoxicillin is a commonly preferred first-line option. The ADA guideline also identifies penicillin V potassium as a first-line agent, while noting advantages of amoxicillin related to spectrum and gastrointestinal tolerability.

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✅ Common First-Line Options

Antibiotic	Typical Adult Regimen*	Clinical Role
Amoxicillin	500 mg every 8 hours	Preferred first-line option when a penicillin antibiotic is appropriate
Penicillin V	500 mg every 6 hours	Narrow-spectrum first-line alternative to amoxicillin

*Regimens shown are examples from the ADA guideline for immunocompetent adults in specific urgent pulpal/periapical scenarios. Patient-specific prescribing must consider current local guidelines, renal function, allergies, interactions, pregnancy, infection severity, and clinical diagnosis. The ADA guideline recommends reassessment within approximately 3 days and discontinuation 24 hours after symptom resolution.

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✅ Alternative Dental Antibiotics
Alternative antibiotics should not automatically be interpreted as stronger antibiotics. They are generally selected because of penicillin allergy, inadequate clinical response, or specific microbiological considerations.

1. Cephalexin
Cephalexin may be considered in selected patients reporting penicillin allergy when there is no history of immediate severe hypersensitivity such as anaphylaxis, angioedema, or urticaria. The ADA guideline lists cephalexin as an alternative in this clinical context.
Cephalosporins should be avoided or carefully evaluated in patients with a history of severe immediate reactions to penicillins.

2. Azithromycin
Azithromycin is an alternative for patients with a history of severe immediate penicillin hypersensitivity when an appropriate systemic antibiotic is required. The ADA guideline includes a loading dose of 500 mg followed by 250 mg daily for four additional days.
Its use should remain selective because antimicrobial resistance patterns and patient-specific factors must be considered.

3. Metronidazole
Metronidazole provides strong activity against anaerobic bacteria and may be used as an adjunct to a penicillin when the initial response is inadequate or when additional anaerobic coverage is clinically appropriate.
It can also be used as an alternative in certain penicillin-allergic patients according to UK dental prescribing guidance. However, prescribing recommendations vary by jurisdiction.

4. Amoxicillin-Clavulanate
Amoxicillin-clavulanate is generally not required as the initial antibiotic for routine odontogenic infections. It may be considered when appropriate first-line therapy fails and the clinical diagnosis, adherence, and source control have been reassessed.
The ADA chairside guideline identifies amoxicillin-clavulanate as an option after failure of first-line therapy rather than as the routine initial choice.

5. Clindamycin: Why Its Role Has Changed
Although older dental guidelines included clindamycin as an alternative for patients with severe penicillin allergy, contemporary stewardship recommendations have moved away from routine use.
Clindamycin has a comparatively high risk of Clostridioides difficile infection and other serious adverse effects. A 2024 Therapeutics Letter specifically recommends avoiding clindamycin for initial treatment and prophylaxis of dental infections when safer alternatives are available.
The 2026 ADA stewardship statement further reinforces the need to minimize unnecessary antibiotic exposure and select agents according to evidence-based indications.

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✅ First-Line vs Alternative Antibiotics: Practical Comparison

Clinical Situation	Preferred Approach	Potential Alternative
Antibiotic indicated; no penicillin allergy	Amoxicillin	Penicillin V
Reported penicillin allergy without severe immediate reaction	Evaluate allergy history carefully	Cephalexin may be appropriate in selected patients
Severe immediate penicillin allergy	Avoid penicillin-class therapy	Azithromycin or another guideline-supported alternative
Inadequate response to first-line therapy	Reassess diagnosis, adherence, and source control	Metronidazole adjunct or amoxicillin-clavulanate when indicated
Routine initial treatment	Use the narrowest appropriate agent	Avoid routine clindamycin

✅ How Should Treatment Failure Be Managed?
Failure to improve should not automatically lead to a broader antibiotic. The clinician should first reassess:

1. The diagnosis
2. Adequacy of drainage or other source control
3. Patient adherence
4. Allergy history and drug interactions
5. Development of spreading or systemic infection
6. The need for endodontic, periodontal, surgical, or hospital-based management
The ADA recommends reassessment at approximately 3 days when antibiotics are prescribed for the relevant urgent dental conditions. If the condition worsens or there is concern for a deep-space infection or threat to life, urgent medical evaluation is required.

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✅ Antibiotic Stewardship in Dentistry
The 2026 ADA clinical practice statement emphasizes that appropriate prescribing means using antibiotics only when clinically indicated, selecting an appropriate agent, dose, and duration, and integrating antimicrobial stewardship into routine dental practice.
A broad-spectrum antibiotic should not be selected simply because it appears more powerful. Unnecessary exposure increases the risk of adverse drug reactions, microbiome disruption, Clostridioides difficile infection, and antimicrobial resistance.

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💬 Discussion
The distinction between first-line and alternative dental antibiotics is increasingly important because contemporary dental antibiotic prescribing is moving toward a more conservative, evidence-based approach.
Amoxicillin remains a major first-line option when systemic therapy is genuinely indicated, while penicillin V remains a narrow-spectrum alternative. Alternative agents should be selected according to specific clinical circumstances rather than prescribed routinely.
Importantly, antibiotic selection cannot compensate for inadequate source control. Drainage and definitive dental treatment remain fundamental components of managing odontogenic infection. The increasing concern regarding clindamycin-associated adverse events also demonstrates why older prescribing habits should be periodically reassessed against current safety evidence.
The most appropriate antibiotic is therefore not necessarily the broadest-spectrum agent, but the narrowest effective treatment for the correct clinical indication.

✍️ Conclusion
Dental antibiotics should be prescribed selectively and strategically. For patients who genuinely require systemic therapy, amoxicillin or penicillin V are established first-line options in relevant odontogenic infections. Cephalexin, azithromycin, metronidazole, or amoxicillin-clavulanate may have specific roles depending on allergy status, treatment response, and clinical circumstances.
The contemporary approach prioritizes definitive dental treatment, appropriate antibiotic selection, short effective therapy, reassessment, and antimicrobial stewardship. Routine use of broad-spectrum agents or clindamycin should be avoided when safer, evidence-supported alternatives are available.

🎯 Clinical Recommendations
▪️ Confirm that an antibiotic is actually indicated before prescribing.
▪️ Prioritize source control and definitive dental treatment rather than antibiotic therapy alone.
▪️ Use amoxicillin or penicillin V as first-line options when systemic therapy is indicated and there is no relevant penicillin allergy.
▪️ Obtain a precise history of the type and severity of antibiotic allergy before selecting an alternative.
▪️ Reserve broader-spectrum therapy for specific clinical circumstances, particularly after reassessment of treatment failure.
▪️ Avoid routine clindamycin use because of its unfavorable safety profile.
▪️ Reassess patients receiving antibiotics and modify therapy when the diagnosis, response, or source-control strategy warrants it.
▪️ Follow current local and national prescribing guidelines for dose, duration, contraindications, interactions, pregnancy, pediatric patients, and medically complex patients.

📚 References

✔ American Dental Association Council on Scientific Affairs. (2026). Antibiotic stewardship: Balancing patient care and public health: American Dental Association Council on Scientific Affairs clinical practice statement. Journal of the American Dental Association. Advance online publication. https://doi.org/10.1016/j.adaj.2026.07.013
✔ Lockhart, P. B., Tampi, M. P., Abt, E., Aminoshariae, A., Durkin, M. J., Fouad, A. F., Gopal, P., Hatten, B. W., Kennedy, E., Lang, M. S., Patton, L. L., Paumier, T., Suda, K. J., Pilcher, L., Urquhart, O., O'Brien, K. K., & Carrasco-Labra, A. (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
✔ Perry, T. (2024). Rethink clindamycin for dental patient safety. Therapeutics Initiative, University of British Columbia. https://www.ncbi.nlm.nih.gov/books/NBK608182/
✔ Tampi, M. P., Pilcher, L., Urquhart, O., Kennedy, E., O'Brien, K. K., Lockhart, P. B., Abt, E., Aminoshariae, A., Durkin, M. J., Fouad, A. F., Gopal, P., Hatten, B. W., Lang, M. S., Patton, L. L., & Paumier, T. (2019). Antibiotics for the urgent management of symptomatic irreversible pulpitis, symptomatic apical periodontitis, and localized acute apical abscess: Systematic review and meta-analysis—A report of the American Dental Association. Journal of the American Dental Association, 150(12), e179–e216. https://doi.org/10.1016/j.adaj.2019.09.011
✔ Thornhill, M. H., Dayer, M. J., Durkin, M. J., Lockhart, P. B., & Baddour, L. M. (2019). Risk of adverse reactions to oral antibiotics prescribed by dentists. Journal of Dental Research, 98(10), 1081–1087. https://doi.org/10.1177/0022034519863645

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Cellulitis vs Abscess: Key Dental Differences

Dental cellulitis and odontogenic abscess are common manifestations of bacterial infection originating from the teeth or surrounding tissues. Although both conditions can produce pain, swelling, and tenderness, they differ in their pathological stage, clinical presentation, and management.

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Recognizing the distinction is clinically important because cellulitis represents a diffuse inflammatory infection, whereas an abscess is a localized collection of purulent material.

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An untreated odontogenic infection may progress through different stages and spread into adjacent fascial spaces, potentially resulting in serious complications.

✅ Cellulitis vs Abscess: What Is the Difference?

Feature	Cellulitis	Abscess
Pathology	Diffuse infection and inflammation of soft tissues	Localized collection of pus
Swelling	Diffuse, poorly defined	More localized and usually well defined
Consistency	Firm, indurated, or “board-like”	May become fluctuant as pus accumulates
Pus	Usually not clinically evident	Purulent material is typically present
Progression	Can spread rapidly through tissue planes	May develop after progressive infection and tissue liquefaction
Main treatment principle	Control the source and assess the need for antimicrobial therapy	Control the source and provide drainage when indicated
Airway risk	Can become significant when deep spaces are involved	Can become significant when the abscess extends into deep fascial spaces

The clinical distinction is not always absolute. Cellulitis and abscess may represent successive stages of the same odontogenic infection, and a patient may present with both diffuse inflammation and a localized purulent collection.

✅ Clinical Features of Dental Cellulitis
Odontogenic cellulitis generally produces a diffuse, painful swelling with tissue induration. The involved tissues may be erythematous, warm, and tender. Fluctuation is usually absent because a mature purulent cavity has not yet developed.
The infection can extend along facial and cervical fascial spaces, particularly when the primary dental source remains untreated. The anatomical location is therefore important when assessing severity. Infections involving the submandibular, sublingual, lateral pharyngeal, or retropharyngeal spaces require greater concern than infections confined to low-risk superficial spaces.

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✅ Clinical Features of a Dental Abscess
A dental abscess is characterized by a localized accumulation of purulent material. Depending on its anatomical location, the swelling may be fluctuant, although deep abscesses may not demonstrate obvious fluctuation on intraoral examination.

Common presentations include:
▪️ Localized swelling and tenderness
▪️ Spontaneous pain or pain on palpation
▪️ Purulent drainage or a sinus tract
▪️ Tooth tenderness to percussion or palpation
▪️ Possible regional lymphadenopathy
▪️ Fever or malaise when systemic involvement is present
Odontogenic abscesses may arise from pulpal, periapical, periodontal, or pericoronal sources. Definitive treatment requires identification and management of the underlying cause.

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✅ Diagnosis: Cellulitis vs Abscess
Diagnosis is primarily clinical and should include assessment of:

1. History and progression: onset, rate of swelling, pain, fever, and previous dental treatment.
2. Clinical examination: extent of swelling, induration, fluctuation, intraoral findings, trismus, and lymphadenopathy.
3. Dental source: caries, pulpal necrosis, periodontal disease, pericoronitis, or a previously treated tooth.
4. Systemic status: temperature, malaise, dehydration, and other evidence of systemic involvement.
5. Airway assessment: dysphagia, odynophagia, drooling, voice changes, floor-of-mouth elevation, or respiratory difficulty.
When the presence or extent of a deep collection is uncertain, ultrasound, computed tomography, or magnetic resonance imaging may assist diagnosis depending on the anatomical location and clinical circumstances. Imaging can help distinguish cellulitis from a fluid collection and identify deep-space involvement.

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✅ Treatment Principles

Cellulitis
Management should focus primarily on eliminating the odontogenic source. Depending on the tooth and clinical situation, this may involve endodontic treatment or extraction.
Antibiotics are not a substitute for definitive dental treatment. For immunocompetent adults with localized odontogenic conditions, the ADA recommends prioritizing definitive dental treatment rather than routinely prescribing systemic antibiotics. Antibiotics become appropriate when there is systemic involvement or when infection is spreading and definitive treatment alone is insufficient or cannot be promptly performed.

Abscess
When a localized collection of pus is present, drainage is a central component of management, together with elimination of the dental source. Depending on the clinical situation, drainage may be achieved through the root canal, extraction, or incision and drainage.
Antibiotics should be considered according to the patient's systemic condition, extent of infection, risk of progression, and ability to obtain adequate source control. For immunocompetent adults with localized acute apical abscess, the ADA guideline recommends urgent definitive dental treatment and specifies circumstances in which systemic antibiotics are indicated.

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✅ When Is Urgent Referral Required?
Urgent medical or oral and maxillofacial referral should be considered when an odontogenic infection demonstrates:

▪️ Airway compromise or respiratory difficulty
▪️ Significant dysphagia or inability to swallow saliva
▪️ Rapidly progressive swelling
▪️ Floor-of-mouth elevation
▪️ Significant trismus
▪️ Extension into deep neck or other high-risk fascial spaces
▪️ Systemic toxicity or sepsis
▪️ Failure to respond to appropriate initial management
Deep-space odontogenic infections can progress to severe complications, including airway obstruction, mediastinitis, orbital complications, intracranial infection, and sepsis.

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💬 Discussion
The distinction between cellulitis and dental abscess is clinically useful but should not be interpreted as a rigid dichotomy. Odontogenic infections can evolve from an early diffuse inflammatory process to localized abscess formation, while infection can simultaneously spread through adjacent anatomical spaces.
The most important management principle is therefore not simply deciding whether the swelling is cellulitis or an abscess, but determining the severity, anatomical extent, source, presence of a drainable collection, and risk of systemic or airway complications. Definitive elimination of the dental source remains fundamental, while antibiotics serve as an adjunct in appropriately selected cases.

✍️ Conclusion
Dental cellulitis is primarily a diffuse soft-tissue infection, whereas an abscess is a localized purulent collection. Cellulitis is typically firm and poorly defined, while an abscess may become fluctuant and localized. However, both conditions can coexist or represent stages of the same odontogenic infection.
Accurate assessment of infection severity, fascial-space involvement, systemic signs, and airway risk is essential. Treatment should prioritize source control, with drainage for an established collection and antibiotics reserved for appropriate clinical indications rather than used as a replacement for definitive dental treatment.

🎯 Clinical Recommendations
▪️ Differentiate diffuse induration from a localized collection, but recognize that the two processes may coexist.
▪️ Identify and eliminate the odontogenic source promptly rather than relying on antibiotics alone.
▪️ When an abscess is clinically or radiographically identified, evaluate whether drainage is required.
▪️ Assess airway and deep-space involvement whenever swelling extends beyond the immediate dentoalveolar region.
▪️ Use systemic antibiotics according to clinical severity and evidence-based indications, particularly when systemic involvement or progressive spread is present.
▪️ Reassess patients when symptoms progress or fail to improve after appropriate source control.

📚 References

✔ American Dental Association. (2019). Evidence-based clinical practice guideline on antibiotic use for the urgent management of pulpal- and periapical-related dental pain and intra-oral swelling. Journal of the American Dental Association, 150(10), 906–921.e12. https://doi.org/10.1016/j.adaj.2019.08.020
✔ Jevon, P., Abdelrahman, A., & Pigadas, N. (2020). Management of odontogenic infections and sepsis: An update. British Dental Journal, 229(6), 363–370. https://doi.org/10.1038/s41415-020-2114-5
✔ Ogle, O. E. (2017). Odontogenic infections. Dental Clinics of North America, 61(2), 235–252. https://doi.org/10.1016/j.cden.2016.11.004
✔ Zawiślak, E., Nowak, R., & others. (2022). Current approaches to the diagnosis and management of odontogenic abscesses. International Journal of Environmental Research and Public Health.
✔ Hoerter, J. E., & Malkin, B. D. (2023). Odontogenic orofacial space infections. In StatPearls. StatPearls Publishing.

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Amoxicillin + Metronidazole in Dentistry: When to Use It

Amoxicillin + metronidazole is a combination of systemic antibiotics used in selected dental infections because the two agents provide complementary antimicrobial activity.

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Amoxicillin primarily targets susceptible aerobic and facultative bacteria, whereas metronidazole provides strong activity against anaerobic microorganisms.

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However, the combination should not be prescribed routinely for dental pain, localized dental infections, or uncomplicated periodontal disease.
Current antibiotic-stewardship recommendations emphasize definitive dental treatment, including drainage, endodontic treatment, extraction, or periodontal instrumentation, as the primary intervention whenever appropriate.

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✅ When Is Amoxicillin + Metronidazole Used in Dentistry?
The combination has two main clinical contexts: selected severe odontogenic infections and specific periodontal cases in which systemic antibiotics are used as an adjunct to mechanical periodontal therapy.

1. Severe or spreading odontogenic infections
Systemic antibiotics may be appropriate when an odontogenic infection demonstrates spreading infection or systemic involvement, particularly when there is fever, malaise, progressive swelling, lymphadenopathy, or involvement of multiple anatomical spaces.
In these situations, antibiotics must complement, rather than replace, source control. Incision and drainage, extraction, or endodontic treatment should be performed whenever indicated.
For uncomplicated localized acute apical abscesses in immunocompetent adults, antibiotics are generally unnecessary when definitive dental treatment can be provided promptly.

2. Selected patients with advanced periodontitis
The combination has been studied extensively as an adjunct to subgingival instrumentation in patients with severe or rapidly progressing periodontitis.
The strongest evidence concerns patients with generalized Stage III periodontitis, particularly younger patients and cases with deep periodontal pockets. The European Federation of Periodontology does not recommend routine systemic antibiotics for periodontitis but states that specific systemic antibiotics may be considered in selected patient categories.
Clinical trials have demonstrated additional reductions in probing depth and improvements in clinical attachment when amoxicillin + metronidazole is combined with mechanical periodontal treatment in appropriately selected patients.

3. Periodontal infections with a substantial anaerobic component
The rationale for combining these drugs is particularly relevant when the periodontal microbiota includes substantial populations of anaerobic periodontal pathogens. Metronidazole has potent activity against anaerobic bacteria, while amoxicillin provides complementary activity against susceptible organisms.
This does not mean that microbiological testing is required before every prescription. Rather, the combination should be considered within an overall periodontal diagnosis and treatment plan rather than simply because a patient has bleeding gums or periodontal pockets.

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✅ When Should It Not Be Used?
Amoxicillin + metronidazole should generally not be used for:
▪️ Irreversible pulpitis without systemic involvement
▪️ Symptomatic apical periodontitis without systemic involvement
▪️ Localized acute apical abscess when adequate drainage or definitive dental treatment is available
▪️ Routine treatment of uncomplicated gingivitis
▪️ Routine treatment of periodontitis
▪️ Dental pain alone
▪️ As a substitute for endodontic treatment, extraction, drainage, or periodontal instrumentation
The ADA guideline specifically recommends prioritizing definitive conservative dental treatment rather than antibiotics for most pulpal and periapical conditions.

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✅ Clinical Context and Antibiotic Rationale

Clinical Situation	Role of Amoxicillin + Metronidazole	Primary Management
Localized acute apical abscess	Usually not indicated if definitive treatment is immediately available	Drainage, endodontic treatment, or extraction
Odontogenic infection with systemic involvement	Systemic antibiotic therapy may be indicated; regimen depends on clinical circumstances and local guidance	Source control plus appropriate systemic therapy
Generalized Stage III/Grade C periodontitis	May be considered as an adjunct in selected patients	Subgingival instrumentation and comprehensive periodontal therapy
Routine gingivitis or uncomplicated periodontitis	Not routinely indicated	Biofilm control and appropriate periodontal treatment

✅ Dosage Considerations
The exact regimen should be determined according to the diagnosis, severity, patient factors, local antimicrobial guidelines, and antimicrobial stewardship principles.
In periodontal clinical trials, commonly investigated regimens have included amoxicillin 500 mg plus metronidazole 500 mg, three times daily, for either 3 or 7 days. A randomized clinical trial in Stage III/IV Grade C periodontitis found comparable clinical outcomes with 3 versus 7 days when the antibiotics were used adjunctively with subgingival instrumentation.
These research regimens should not be interpreted as a universal prescription protocol for all dental infections.

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✅ Important Safety Considerations
Before prescribing, clinicians should evaluate:

▪️ Penicillin allergy, including the type and severity of previous reactions.
▪️ Previous adverse reactions to metronidazole.
▪️ Significant hepatic or other relevant medical conditions.
▪️ Potential drug interactions.
▪️ Pregnancy or breastfeeding when clinically relevant.
▪️ Previous antibiotic exposure and risk of antimicrobial resistance.
▪️ The need for urgent referral in patients with rapidly spreading infection, airway compromise, dysphagia, systemic deterioration, or deep-space involvement.
Metronidazole also requires particular attention to medication counseling, including avoidance of alcohol during treatment and for the period recommended by current prescribing information.

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💬 Discussion
The combination of amoxicillin and metronidazole has a well-established evidence base as an adjunct in selected periodontal patients, particularly those with advanced disease and deep periodontal pockets. Randomized trials have demonstrated additional clinical benefits when systemic antibiotics are combined with thorough mechanical periodontal therapy.
Nevertheless, the magnitude of benefit must be balanced against adverse effects, antimicrobial resistance, and broader microbiome consequences. The EFP therefore recommends against routine systemic antibiotic use as an adjunct to periodontal debridement, while allowing consideration in selected patient categories.
For acute odontogenic infections, the clinical principle is different: antibiotics are primarily indicated when infection extends beyond the local site or produces systemic manifestations. The ADA emphasizes that antibiotics should not delay or substitute for definitive dental treatment.

🎯 Clinical Recommendations
▪️ Reserve amoxicillin + metronidazole for clearly defined clinical indications rather than routine dental infections.
▪️ In odontogenic infection, prioritize source control through drainage, endodontic treatment, or extraction.
▪️ Consider systemic antibiotic therapy in selected patients with advanced or rapidly progressing periodontitis, particularly when supported by the overall clinical presentation.
▪️ Avoid prescribing antibiotics solely for dental pain, localized infection, or routine periodontal disease.
▪️ Select the dose and duration according to current local guidelines and patient-specific risk factors.
▪️ Reassess patients who fail to improve; persistent or progressive infection may require microbiological assessment, treatment modification, specialist referral, or hospital management.
▪️ Use the narrowest appropriate antimicrobial regimen and the shortest effective duration to support antibiotic stewardship.

✍️ Conclusion
Amoxicillin + metronidazole in dentistry has a specific rather than universal role. Its principal evidence-supported periodontal application is as an adjunct to mechanical treatment in selected patients with advanced periodontitis, while systemic antibiotics may also be necessary in odontogenic infections with systemic or spreading features.
The key clinical principle is that antibiotics complement definitive dental treatment; they do not replace it. Appropriate patient selection is essential to maximize clinical benefit while minimizing adverse effects and antimicrobial resistance.

📚 References

✔ 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. Journal of the American Dental Association, 150(11), 906–921.e12. https://doi.org/10.1016/j.adaj.2019.08.020
✔ Cosgarea, R., et al. (2022). Clinical, microbiological, and immunological effects of 3- or 7-day systemic antibiotics adjunctive to subgingival instrumentation in patients with aggressive (Stage III/IV Grade C) periodontitis: A randomized placebo-controlled clinical trial. Journal of Clinical Periodontology, 49(11), 1128–1140. https://doi.org/10.1111/jcpe.13676
✔ Guerrero, A., Griffiths, G. S., Nibali, L., Suvan, J., Moles, D. R., Laurell, L., & Tonetti, M. S. (2005). Adjunctive benefits of systemic amoxicillin and metronidazole in non-surgical treatment of generalized aggressive periodontitis: A randomized placebo-controlled clinical trial. Journal of Clinical Periodontology, 32(10), 1096–1107. https://doi.org/10.1111/j.1600-051X.2005.00814.x
✔ Sanz, M., Herrera, D., Kebschull, M., Chapple, I., Jepsen, S., Beglundh, T., Sculean, A., Tonetti, M. S., & EFP Workshop Participants and Methodological Consultants. (2020). Treatment of stage I–III periodontitis—The EFP S3 level clinical practice guideline. Journal of Clinical Periodontology, 47(Suppl. 22), 4–60. https://doi.org/10.1111/jcpe.13290
✔ Zúñiga-Loor, D., Parise-Vasco, J. M., & Montesinos-Guevara, C. (2024). Mechanical debridement combined with amoxicillin and metronidazole compared with mechanical debridement alone for the treatment of chronic periodontitis: An overview of systematic reviews. Dental and Medical Problems, 61(3), 439–446. https://doi.org/10.17219/dmp/158925

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Best Archwire Sequence for Impacted Canines

The orthodontic management of an impacted canine requires more than simply creating space and applying traction. The archwire system must provide adequate alignment, anchorage, torque control, and stabilization while allowing the impacted tooth to be guided through a controlled path into the dental arch.

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Accurate three-dimensional localization is essential because the position and angulation of the impacted canine determine the direction and type of orthodontic force required.

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Poorly controlled mechanics may increase the risk of root resorption, periodontal complications, and unwanted movement of adjacent teeth.
Although different archwire sequences can be clinically effective, a practical fixed-appliance protocol generally progresses from light flexible NiTi wires to rectangular working wires and finally rigid stainless-steel wires. The objective is to establish a sufficiently stable dental arch before significant canine traction is initiated.

1. Initial Alignment and Leveling
The initial phase should focus on correcting rotations, leveling the arch, and establishing sufficient space for the impacted canine.

A commonly used sequence is:
▪️ 0.012–0.014-inch NiTi: initial alignment in moderately irregular arches.
▪️ 0.016-inch NiTi: continued leveling and alignment.
▪️ 0.016 × 0.022-inch or 0.017 × 0.025-inch NiTi: transition to rectangular control.
▪️ 0.019 × 0.025-inch NiTi: development of greater three-dimensional control before the working phase.
The exact sequence should not be considered mandatory. Evidence comparing conventional archwire sequences indicates that different combinations can achieve comparable alignment, supporting individualized selection according to the severity of malalignment and the treatment objectives.
For an impacted canine, however, rapid progression to a rigid rectangular working wire should be avoided if the adjacent teeth are not adequately aligned or if the required space has not been established.

2. Space Creation Before Canine Traction
Before orthodontic traction, the clinician should confirm:

1. Adequate space for the canine crown and root.
2. Correct axial position of the adjacent teeth.
3. Sufficient anchorage for the planned direction of traction.
4. Absence of significant interference with adjacent roots.
5. A clinically appropriate path of eruption.
Radiographic or CBCT assessment may be particularly valuable in complex impactions because three-dimensional localization influences the direction of traction and helps reduce the risk of undesirable contact with adjacent roots.
Canine traction should not be used as a substitute for inadequate space management.

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3. Stabilization Before Traction
One of the most important stages is establishing a rigid and stable archwire before applying substantial traction to the impacted canine.

A practical stabilization sequence can be summarized as follows:

Stage	Typical Archwire	Main Purpose
Initial alignment	0.012–0.014 NiTi	Gentle alignment
Leveling	0.016 NiTi	Leveling and continued alignment
Rectangular control	0.016 × 0.022 or 0.017 × 0.025 NiTi	Torque and root-position control
Pre-traction working phase	0.019 × 0.025 NiTi or equivalent	Arch coordination and control
Stabilization	0.019 × 0.025 stainless steel	Anchorage and three-dimensional stabilization

The 0.019 × 0.025-inch stainless-steel archwire is particularly useful when maximum control of the erupted dentition is required. Its greater rigidity makes it suitable as a stable base for auxiliary mechanics, provided that the brackets are appropriately positioned and the archwire is fully engaged.

4. Why Stainless Steel Is Important During Canine Traction
During traction of an impacted canine, the objective is not simply to move the canine toward the arch. The surrounding teeth must remain sufficiently stable while the force system directs the impacted tooth along a controlled path.

A rigid rectangular stainless-steel base archwire can therefore be used to:
▪️ Limit unwanted tipping of adjacent teeth.
▪️ Improve control of incisor torque.
▪️ Reinforce posterior anchorage.
▪️ Provide a stable platform for auxiliary traction mechanics.
▪️ Reduce unwanted deformation of the main archwire.
For difficult impactions, sectional mechanics or cantilever systems may be preferable to applying traction directly to a flexible continuous archwire. Contemporary literature also describes the use of sectional wires and cantilevers, particularly when additional anchorage is required.

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5. Archwire for the Traction Phase
The traction phase should be considered separately from conventional alignment.

A useful clinical concept is:
Rigid base archwire + controlled auxiliary force + appropriate anchorage
Rather than repeatedly changing the main archwire to accommodate the impacted canine, the clinician can maintain a stable rectangular working archwire and use an auxiliary system such as:
▪️ TMA cantilever
▪️ Stainless-steel auxiliary
▪️ Sectional archwire
▪️ Elastic traction from a controlled attachment
▪️ Temporary anchorage device (TAD), when conventional anchorage is insufficient
The choice depends primarily on the three-dimensional position of the canine, rather than on the archwire sequence itself.
Recent evidence indicates that auxiliary mechanics, including TADs and sectional/cantilever systems, can be important in complex impacted-canine treatment.

6. Stabilization During Space Closure and Canine Integration
Once the canine has been brought sufficiently close to the arch, the main archwire should continue to provide control while the tooth is progressively integrated into the arch.

A typical sequence may therefore be:
0.019 × 0.025 SS → canine integration → finishing adjustments
The rigid stainless-steel wire can remain in place while the canine is progressively aligned, provided that the required movements do not exceed the wire's ability to accommodate them.
If significant finishing corrections are necessary after canine engagement, a 0.017 × 0.025-inch or 0.019 × 0.025-inch TMA wire may provide greater flexibility than stainless steel while retaining useful rectangular control.

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7. Practical Archwire Sequence
For a conventional fixed-appliance case involving a maxillary impacted canine, an evidence-informed clinical sequence can be summarized as:

Phase	Suggested Wire	Clinical Objective
1. Alignment	0.012–0.014 NiTi	Initial alignment
2. Leveling	0.016 NiTi	Leveling and alignment
3. Rectangular alignment	0.016 × 0.022 or 0.017 × 0.025 NiTi	Root and torque control
4. Working phase	0.019 × 0.025 NiTi	Arch coordination and control
5. Stabilization	0.019 × 0.025 SS	Stable base for canine traction
6. Traction	SS base + TMA/sectional auxiliary	Controlled canine movement
7. Finishing	0.017 × 0.025 or 0.019 × 0.025 TMA/SS	Final root and occlusal control

This sequence should be interpreted as a clinical framework rather than a fixed protocol. Archwire selection must be modified according to bracket prescription, slot size, initial malocclusion, periodontal conditions, anchorage requirements, and the canine's location.

💬 Discussion
The principal biomechanical issue in impacted canine treatment is not the number of archwires used but the transition from a flexible alignment system to a sufficiently rigid system capable of controlling the erupted dentition during traction.
Current evidence supports individualized treatment planning based on the canine's three-dimensional position and severity of impaction.
Importantly, successful alignment does not necessarily mean absence of periodontal consequences. A systematic review and meta-analysis found that orthodontically aligned impacted maxillary canines may present modest increases in probing depth, clinical attachment loss, bone loss, and other periodontal differences compared with the contralateral non-impacted canine. However, the certainty of evidence was low to very low.
Therefore, rigid stabilization should facilitate controlled traction rather than justify excessive force. The objective is to move the canine through a biologically and mechanically appropriate path while minimizing unwanted movement of adjacent teeth.

✍️ Conclusion
An effective archwire sequence for impacted canines should progressively establish alignment, rectangular control, and finally a rigid anchorage platform before significant traction is applied.
A practical sequence is light NiTi → rectangular NiTi → 0.019 × 0.025 NiTi → 0.019 × 0.025 stainless steel, followed by controlled traction using a suitable auxiliary system. For complex impactions, sectional wires, cantilevers, or TAD-supported mechanics may provide superior control.
The 0.019 × 0.025-inch stainless-steel archwire is particularly useful as a stabilization wire because it provides a rigid base from which canine traction can be delivered while limiting unwanted movement of the remaining dentition.

🎯 Clinical Recommendations
▪️ Do not initiate substantial canine traction until adequate space and anchorage have been established.
▪️ Use a rigid rectangular stainless-steel base archwire when significant stabilization is required.
▪️ Select the direction of traction according to the three-dimensional canine position, rather than according to a predetermined archwire sequence.
▪️ Consider cantilever, sectional, or TAD-supported mechanics when conventional continuous-arch traction would generate undesirable reciprocal effects.
▪️ Monitor adjacent roots and periodontal tissues throughout treatment, particularly in severely displaced canines.

📚 References

✔ Aquino-Valverde, A. J., et al. (2021). Orthodontic treatment in impacted maxillary canines: A review of the literature. Revista Científica Odontológica, 9(4), e085. https://doi.org/10.21142/2523-2754-0904-2021-085
✔ Bishara, S. E. (1992). Impacted maxillary canines: A review. American Journal of Orthodontics and Dentofacial Orthopedics, 101(2), 159–171. https://doi.org/10.1016/0889-5406(92)70008-X
✔ Grisar, K., Denoiseux, B., Martin, C., Hoppenreijs, T., Calburean, F., Politis, C., & Jacobs, R. (2022). Treatment for critically impacted maxillary canines: Clinical versus scientific evidence—A systematic review. Journal of Stomatology, Oral and Maxillofacial Surgery, 123(3), e12–e19. https://doi.org/10.1016/j.jormas.2021.03.013
✔ Mandall, N. A., Lowe, C., Worthington, H. V., Sandler, J., Derwent, S., Abdi-Oskouei, M., & Ward, S. (2006). Which orthodontic archwire sequence? A randomized clinical trial. European Journal of Orthodontics, 28(6), 561–566. https://doi.org/10.1093/ejo/cjl030
✔ Seehra, J., Alshammari, A., Wazwaz, F., Papageorgiou, S. N., Newton, J. T., & Cobourne, M. T. (2023). Periodontal outcomes associated with impacted maxillary central incisor and canine teeth following surgical exposure and orthodontic alignment: A systematic review and meta-analysis. European Journal of Orthodontics, 45(5), 584–598. https://doi.org/10.1093/ejo/cjad039
✔ Tarkan, H., & Gürbüz, O. Ö. (2026). The impact of orthodontic traction on outcomes in impacted canine management: A quantitative analysis. The Angle Orthodontist, 96(2), 181–191. https://doi.org/10.2319/032125-227.1

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Gingival Recession Treatment: Modern Treatment Options

Gingival recession is characterized by apical displacement of the gingival margin, resulting in exposure of the root surface. It may be associated with dentin hypersensitivity, root caries, non-carious cervical lesions, aesthetic concerns, and progressive loss of soft-tissue coverage.

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Current management is not based on a single treatment for every patient. The appropriate approach depends on the recession depth, interproximal attachment, gingival phenotype, periodontal status, root anatomy, symptoms, aesthetic expectations, and etiologic factors. The contemporary objective is to control modifiable risk factors and, when indicated, obtain stable root coverage.

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✅ What Is the Current Treatment for Gingival Recession?
Treatment can be divided into non-surgical management and periodontal plastic surgery.

Clinical Situation	Current Management
Mild recession without symptoms or progression	Risk-factor control and periodontal maintenance
Dentin hypersensitivity	Desensitizing agents and exposure control
Plaque-related inflammation	Professional periodontal therapy and optimized plaque control
Root caries or cervical lesion	Restorative management when indicated
Aesthetic concern or progressive recession	Periodontal plastic surgery
Localized recession suitable for root coverage	Coronally advanced flap ± connective tissue graft
Multiple adjacent recessions	Tunnel or coronally advanced techniques, usually with connective tissue graft
Limited donor tissue or avoidance of palatal surgery	Collagen or other soft-tissue substitutes may be considered

1. Non-Surgical Management
Not every gingival recession requires surgery. The initial approach should identify and control factors that may contribute to progression or symptoms.

Management may include:
▪️ Improvement of plaque control without traumatizing the marginal tissues.
▪️ Correction of inappropriate oral-hygiene practices when clinically relevant.
▪️ Management of periodontal inflammation or periodontitis.
▪️ Treatment of dentin hypersensitivity with appropriate desensitizing agents.
▪️ Evaluation and treatment of non-carious cervical lesions or root caries.
▪️ Periodic periodontal monitoring to determine whether the recession remains stable.
The evidence regarding traumatic toothbrushing as a direct cause of recession is not completely consistent. Therefore, clinicians should avoid attributing every recession solely to brushing technique and should evaluate the entire clinical context.

2. Connective Tissue Graft With a Coronally Advanced Flap
For a suitable localized gingival recession, the combination of a subepithelial connective tissue graft (CTG) and coronally advanced flap (CAF) remains one of the most predictable approaches for root coverage.
A systematic review and network meta-analysis involving 38 studies found that CTG + CAF ranked highest for mean root coverage, complete root coverage, and gain in keratinized tissue for single recession defects. The authors concluded that this combination can be considered the current gold-standard approach for these indications.

The technique is particularly valuable when the objectives include:
▪️ Root coverage
▪️ Increased gingival thickness
▪️ Increased keratinized tissue
▪️ Reduction of dentin hypersensitivity
▪️ Improvement of gingival aesthetics
▪️ Long-term soft-tissue stability

3. Tunnel Techniques
Tunnel procedures combined with a connective tissue graft are another important option, particularly for multiple adjacent recessions.
Evidence indicates that tunnel and coronally advanced flap approaches can provide comparable overall root-coverage outcomes in appropriately selected cases, although the optimal technique depends on defect morphology, tissue thickness, interdental anatomy, and operator expertise.

4. Collagen Matrices and Other Alternatives
When harvesting an autogenous graft is undesirable or contraindicated, xenogeneic collagen matrices, acellular dermal matrices, and other soft-tissue substitutes can be considered.
These materials may reduce the need for a palatal donor site and can reduce postoperative morbidity. However, current evidence generally continues to support autogenous connective tissue grafts as the most predictable option, particularly when maximum root coverage and soft-tissue augmentation are priorities.

5. Enamel Matrix Derivative
Enamel matrix derivative (EMD) may be used as an adjunct to selected root-coverage procedures. A systematic review and meta-analysis found a statistically significant improvement in root coverage when EMD was added to CAF + CTG, although the magnitude of the additional benefit was relatively modest.
Therefore, EMD should generally be regarded as an adjunct rather than a replacement for the fundamental surgical technique.

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✅ How Should the Recession Be Evaluated?
Modern diagnosis should consider the interproximal clinical attachment level, rather than relying exclusively on the traditional Miller classification.

The Cairo classification distinguishes:
▪️ RT1: recession without interproximal attachment loss.
▪️ RT2: interproximal attachment loss that is equal to or less than the buccal attachment loss.
▪️ RT3: interproximal attachment loss greater than the buccal attachment loss.
The amount of interproximal attachment is clinically important because it influences the predictability of complete root coverage.

A complete periodontal assessment should also consider:
▪️ Recession depth and width
▪️ Gingival phenotype
▪️ Keratinized tissue
▪️ Interproximal attachment
▪️ Root prominence
▪️ Tooth position
▪️ Periodontal inflammation
▪️ Presence of cervical lesions
▪️ Patient symptoms and aesthetic expectations

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✅ When Is Surgery Indicated?
Root-coverage surgery should be considered when the recession produces significant aesthetic concerns, persistent hypersensitivity, progressive tissue loss, root caries risk, or other clinically relevant problems that cannot be adequately managed with conservative measures.
However, surgery should not be performed simply because a recession is visible. Stable, asymptomatic recession without functional or aesthetic concerns may be managed conservatively with monitoring and risk-factor control.
Untreated recession can progress over time in some patients; therefore, periodic assessment is appropriate even when surgery is not initially indicated.

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💬 Discussion
The current evidence supports an individualized, defect-based approach to gingival recession. Conservative management remains appropriate for stable and asymptomatic defects, whereas surgical root coverage is indicated when symptoms, aesthetics, progression, or tissue-management objectives justify intervention.
For appropriately selected single recession defects, coronally advanced flap combined with a subepithelial connective tissue graft remains the most predictable reference treatment. Tunnel techniques provide an important alternative for multiple recessions, while collagen matrices and other substitutes can be considered when an autogenous graft is unsuitable or when reduced donor-site morbidity is prioritized.
The presence of a non-carious cervical lesion should also be identified before surgery because the altered cemento-enamel junction and root-surface anatomy can affect the predictability of root coverage and may require a combined restorative-periodontal approach.

✍️ Conclusion
The current treatment of gingival recession begins with accurate diagnosis and control of modifiable risk factors. Non-surgical management is appropriate for many stable defects, while periodontal plastic surgery is indicated when root coverage, symptom control, tissue augmentation, or aesthetic improvement is required.
For suitable localized defects, connective tissue grafting combined with a coronally advanced flap remains the most evidence-supported and predictable approach. Alternative techniques and biomaterials should be selected according to defect characteristics, patient preferences, donor-site considerations, and the clinician's surgical expertise.

🎯 Clinical Recommendations
1. Classify the recession and assess interproximal attachment before selecting a root-coverage technique.
2. Control periodontal inflammation and modifiable risk factors before surgery.
3. For predictable root coverage of appropriate localized defects, consider CAF + subepithelial connective tissue graft as the reference approach.
4. For multiple adjacent recessions, consider tunnel or coronally advanced techniques combined with soft-tissue grafting according to anatomy and operator expertise.
5. Consider collagen matrices or other substitutes when an autogenous donor site is undesirable or contraindicated, recognizing that clinical outcomes may differ from those obtained with CTG.
6. Evaluate non-carious cervical lesions before surgery and consider coordinated restorative-periodontal treatment when indicated.
7. Maintain long-term periodontal supportive care and clinical monitoring, even after successful root-coverage therapy.

📚 References

✔ Chambrone, L., Botelho, J., Machado, V., Mascarenhas, P., Mendes, J. J., & Avila-Ortiz, G. (2022). Does the subepithelial connective tissue graft in conjunction with a coronally advanced flap remain as the gold standard therapy for the treatment of single gingival recession defects? A systematic review and network meta-analysis. Journal of Periodontology, 93(9), 1336–1352. https://doi.org/10.1002/JPER.22-0167
✔ Chapple, I. L. C., Mealey, B. L., Van Dyke, T. E., Bartold, P. M., Dommisch, H., Eickholz, P., Geisinger, M. L., Genco, R. J., Glogauer, M., Goldstein, M., Griffin, T. J., Holmstrup, P., Johnson, G. K., Kapila, Y., Lang, N. P., Meyle, J., Murakami, S., Plemons, J., Romito, G. A., Shapira, L., Teughels, W., Trombelli, L., Walter, C., Wimmer, G., & Xenoudi, P. (2018). Periodontal health and gingival diseases and conditions on an intact and a reduced periodontium: Consensus report of workgroup 1 of the 2017 World Workshop. Journal of Clinical Periodontology, 45(Suppl. 20), S68–S77. https://doi.org/10.1111/jcpe.12940
✔ Cairo, F., Nieri, M., Pagliaro, U. (2008). Treatment of gingival recession with coronally advanced flap procedures: A systematic review. Journal of Clinical Periodontology, 35(8 Suppl.), 136–162. https://doi.org/10.1111/j.1600-051X.2008.01267.x
✔ Gennai, S., Ben Guiza, Z., Orsolini, C., & Gosset, M. (2022). The influence of non-carious lesions in the surgical treatment of gingival recession: A systematic review and meta-analysis. Journal of Dentistry, 117, 103922. https://doi.org/10.1016/j.jdent.2021.103922
✔ Kasaj, A., & Willershausen, B. (2021). Treatment of gingival recession: When and how? International Dental Journal, 71(3), 178–187. https://doi.org/10.1111/idj.12617
✔ Rajapakse, P. S., McCracken, G. I., Gwynnett, E., Steen, N. D., Guentsch, A., & Heasman, P. A. (2007). Does tooth brushing influence the development and progression of non-inflammatory gingival recession? A systematic review. Journal of Clinical Periodontology, 34(12), 1046–1061. https://doi.org/10.1111/j.1600-051X.2007.01149.x

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