Best Archwire Sequence for Open Bite Treatment

Anterior open bite (AOB) is a challenging orthodontic malocclusion because successful correction depends on controlling the vertical position and inclination of both anterior and posterior teeth, while addressing the underlying skeletal, dental, and functional factors.

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Dental Article 🔽 Orthodontic Archwire Selection Guide: Types and Functions ... Different archwires have different properties. Some are flexible and ideal for the beginning of treatment, while others are stronger and provide precise tooth control during the final stages.

In patients treated with fixed appliances, archwire selection alone does not determine treatment success. The wire sequence must be integrated with appropriate vertical mechanics, anchorage control, and, when indicated, auxiliary appliances.

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Current evidence supports individualized treatment based on the etiology and severity of the open bite. In particular, posterior intrusion with temporary anchorage devices (TADs) can provide meaningful vertical control, whereas MEAW mechanics and vertical elastics can be useful when dentoalveolar compensation is appropriate.

🔹 What Is the Best Archwire Sequence for Open Bite Treatment?
There is no single archwire sequence supported as superior for every open-bite patient. A practical sequence for patients treated with conventional fixed appliances is:

Treatment Phase	Typical Archwire	Primary Objective
Initial alignment	0.012–0.014 NiTi	Gentle alignment and leveling
Continued alignment	0.016–0.018 NiTi	Progression of alignment while maintaining flexibility
Early working phase	0.016 × 0.022 or 0.017 × 0.025 NiTi	Begin three-dimensional control
Vertical-control phase	0.017 × 0.025 or 0.019 × 0.025 stainless steel/TMA	Rigidity, torque expression, and auxiliary mechanics
Finishing	0.017 × 0.025 or 0.019 × 0.025 stainless steel	Root positioning and occlusal detailing

The exact dimensions should be modified according to bracket prescription, arch form, tooth position, periodontal support, skeletal pattern, and the amount of vertical correction required. The literature does not establish these wire dimensions as a universal evidence-based sequence.

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1. Initial Alignment: Round NiTi
Treatment generally begins with a light round nickel-titanium (NiTi) archwire.
Typical progression may include:
0.012 NiTi → 0.014 NiTi → 0.016 NiTi → 0.018 NiTi
The purpose is primarily alignment and leveling rather than active open-bite closure.
In an open-bite patient, excessive early leveling should be avoided when it produces undesirable posterior extrusion or uncontrolled vertical changes. The clinician should evaluate the vertical position of the molars and incisors before progressing to larger wires.

2. Transition to Rectangular NiTi
Once sufficient alignment has been achieved, a rectangular NiTi archwire can provide improved three-dimensional control.
Examples include:
0.016 × 0.022 NiTi → 0.017 × 0.025 NiTi
or, depending on the bracket system:
0.018 × 0.025 NiTi
This phase allows progressive expression of torque and tip control while maintaining some flexibility.
The rectangular wire should not be considered the principal mechanism for closing the open bite. Its role is to establish adequate tooth control before more rigid vertical mechanics are introduced.

3. Working Archwire: Stainless Steel or TMA
When alignment and leveling are substantially complete, a more rigid rectangular archwire is generally preferable for controlled vertical mechanics.
Common options include:
▪️ 0.017 × 0.025 stainless steel
▪️ 0.019 × 0.025 stainless steel
▪️ 0.017 × 0.025 TMA when greater flexibility is desirable
A rigid working archwire is particularly useful when applying vertical elastics, extrusion mechanics, TAD-supported mechanics, or MEAW-type adjustments.
The choice between 0.017 × 0.025 and 0.019 × 0.025 should not be predetermined. A larger wire may improve control but can also increase force levels and reduce flexibility. Periodontal support and tooth mobility must therefore be considered.

4. Vertical Elastics: An Important Auxiliary
Anterior vertical elastics are frequently used after adequate arch coordination has been established.
They can be attached between:
▪️ maxillary and mandibular incisors,
▪️ canine-to-canine regions, or
▪️ selected anterior segments according to the required force system.
Their principal effect is dentoalveolar extrusion of the anterior teeth, so they are most appropriate when anterior extrusion is compatible with the patient's smile esthetics, incisor display, and skeletal pattern.
Clinical studies have demonstrated successful open-bite correction using vertical elastics combined with posterior vertical control and MEAW mechanics.

5. TADs for Posterior Vertical Control
For patients in whom excessive posterior dentoalveolar height contributes significantly to the open bite, temporary anchorage devices (TADs) may provide a more appropriate biomechanical strategy than relying primarily on anterior extrusion.
TAD-supported posterior intrusion can produce:
▪️ molar intrusion
▪️ counterclockwise mandibular autorotation in appropriate patients
▪️ reduction of anterior facial height in selected cases
▪️ improvement of anterior overbite

A 2025 systematic review and meta-analysis reported a pooled mean molar intrusion of approximately 1.70 mm with TAD-supported treatment, although substantial heterogeneity existed among studies.
Another systematic review reported approximately 2.89 mm of maxillary molar intrusion with skeletal anchorage, with greater effects reported for miniplates than miniscrews.
Therefore, TADs should be considered particularly when the treatment objective is posterior intrusion rather than simply anterior extrusion.

🔹 Additional Appliances Used With Fixed Brackets
Open-bite treatment frequently requires auxiliary appliances in addition to the archwire.

Auxiliary	Main Indication	Principal Biomechanical Role
Vertical elastics	Mild–moderate dentoalveolar AOB	Anterior extrusion and settling
TADs / miniscrews	Skeletal or posterior vertical excess	Posterior intrusion and anchorage
Palatal crib	Persistent tongue-thrusting or habit-related AOB	Habit modification and tongue control
Bonded lingual spurs	Selected patients with abnormal tongue posture or habits	Restriction of anterior tongue pressure
MEAW	More complex dentoalveolar or skeletal open bite	Posterior uprighting, occlusal-plane control, and anterior extrusion
Posterior bite blocks	Selected growing patients	Vertical control and posterior eruption modification
High-pull headgear / chin cup	Selected growing patients	Additional orthopedic and vertical control

Evidence for habit-breaking appliances is strongest in growing patients with a functional component. Systematic reviews have found that palatal cribs, bonded spurs, and related appliances can improve overbite, although the certainty of evidence varies.

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🔹 MEAW Mechanics: When Should They Be Considered?
The Multiloop Edgewise Archwire (MEAW) technique remains an option for selected open-bite patients, particularly when detailed control of posterior tooth inclination and the occlusal plane is required.
A typical MEAW approach uses a rectangular stainless-steel wire with multiple loops and is frequently combined with vertical elastics.
Clinical studies have reported approximately 4 mm of overbite improvement following MEAW therapy, with favorable stability reported in selected patients. However, much of the literature consists of observational studies and treatment reports rather than high-level comparative trials.
Consequently, MEAW should be regarded as a specific biomechanical technique, not as a universally superior archwire sequence.

🔹 Archwire Sequence According to Treatment Objective
The most appropriate sequence depends more on the vertical problem being treated than on wire size alone.

Clinical Situation	Preferred Strategy
Mild dental open bite	Alignment → rectangular working wire → vertical elastics
Open bite associated with tongue habit	Fixed appliances + habit control/crib or spurs + vertical mechanics
Increased posterior dentoalveolar height	Rigid rectangular wire + TAD-supported molar intrusion
Significant skeletal open bite in a nonsurgical patient	Rigid rectangular mechanics ± MEAW + TADs/elastics
Severe skeletal discrepancy	Orthodontic camouflage or orthognathic surgery, depending on diagnosis
Finishing after bite closure	Rigid rectangular stainless steel + controlled settling

💬 Discussion
The principal limitation of describing a single “best archwire sequence” is that open bite is not a uniform biomechanical problem. A patient with predominantly anterior dentoalveolar deficiency requires a different force system from a patient with excessive posterior dentoalveolar height or a pronounced skeletal vertical pattern.
The current evidence increasingly favors vertical control rather than indiscriminate anterior extrusion when posterior vertical excess is present. TAD-supported molar intrusion has demonstrated clinically relevant improvements in overbite, although treatment outcomes vary substantially between studies.
MEAW mechanics can also produce substantial open-bite correction, but the evidence base is less robust and should not be interpreted as proof that MEAW is superior to conventional rectangular archwires combined with appropriate auxiliaries.
Long-term stability remains an important consideration. A systematic review of TAD-supported molar intrusion found approximately 1.23 mm of standardized overbite relapse, with reported molar relapse of approximately 12% for maxillary molars and 27.2% for mandibular molars. The certainty of evidence was low to very low.
Therefore, etiologic diagnosis, vertical anchorage, controlled tooth movement, and retention are more important than selecting a particular wire sequence in isolation.

🎯 Clinical Recommendations
1. Do not use a fixed archwire sequence for every open-bite patient. Adapt wire progression to the vertical diagnosis and periodontal condition.
2. Use round NiTi primarily for alignment, progressing to rectangular NiTi once adequate alignment permits three-dimensional control.
3. Introduce rigid rectangular mechanics before demanding vertical movements with elastics, TADs, or MEAW.
4. When posterior vertical excess is a major component, prioritize posterior intrusion rather than relying exclusively on anterior extrusion.
5. Use TADs when reliable posterior anchorage and intrusion are required, particularly in nongrowing patients with skeletal or dentoalveolar vertical excess.
6. Reserve MEAW mechanics for cases in which its specific control of posterior inclination and the occlusal plane provides a biomechanical advantage.
7. Plan retention from the beginning. Open-bite correction has a recognized relapse tendency, particularly when the original functional or skeletal factors remain unresolved.

✍️ Conclusion
The best archwire sequence for open bite treatment is not a single standardized progression of wire sizes. A practical approach is to begin with light round NiTi for alignment, transition to rectangular NiTi for three-dimensional control, and use a rigid rectangular stainless-steel or TMA working wire for vertical mechanics and finishing.
However, the decisive factor is the force system applied to the malocclusion. Vertical elastics may be sufficient in mild dentoalveolar cases, whereas TAD-supported posterior intrusion or MEAW mechanics may be more appropriate when greater vertical control is required. The final treatment strategy should therefore be based on the patient's skeletal pattern, posterior vertical dimension, incisor display, functional factors, growth status, and periodontal support rather than on archwire size alone.

📚 References

✔ Alsafadi, A. S., Alabdullah, M. M., Saltaji, H., Abdo, A., & Youssef, M. (2016). Effect of molar intrusion with temporary anchorage devices in patients with anterior open bite: A systematic review. Progress in Orthodontics, 17, 9. https://doi.org/10.1186/s40510-016-0122-4
✔ Burgos-Lancero, P., Ibor-Miguel, M., Marqués-Martínez, L., Boo-Gordillo, P., García-Miralles, E., & Guinot-Barona, C. (2025). Correction of anterior open bite using temporary anchorage devices: A systematic review and meta-analysis. Journal of Clinical Medicine, 14(14), 4958. https://doi.org/10.3390/jcm14144958
✔ Kim, Y. H., Han, U. K., Lim, D. D., & Serraon, M. L. (2000). Stability of anterior openbite correction with multiloop edgewise archwire therapy: A cephalometric follow-up study. American Journal of Orthodontics and Dentofacial Orthopedics, 118(1), 43–54. https://doi.org/10.1067/mod.2000.104830
✔ Omidkhoda, M., Bardideh, E., Jahanbin, A., & Zarei, M. (2023). Effects of posterior intrusion using skeletal anchorage on treating anterior open bite: A systematic review and meta-analysis. Journal of Dental Research, Dental Clinics, Dental Prospects, 17, 196–210. https://doi.org/10.34172/joddd.2023.40754
✔ Papageorgiou, S. N., Konstantinidis, I., Papadopoulou, K., Jäger, A., & Bourauel, C. (2014). A systematic review and meta-analysis of experimental clinical evidence on initial aligning archwires and archwire sequences. Orthodontics & Craniofacial Research, 17(4), 197–215. https://doi.org/10.1111/ocr.12048
✔ Peterkin, C., Abu Arqub, S., Murphy, N., Karanth, D., & Dolce, C. (2024). A retrospective comparative cephalometric evaluation of non-extraction multiloop edgewise archwire and bicuspid extraction therapies in anterior open bite treatment. Clinical Oral Investigations, 28, 569. https://doi.org/10.1007/s00784-024-05966-y

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Pediatric Endodontics: Current Concepts and Techniques

Pediatric endodontics focuses on preserving primary and immature permanent teeth affected by dental caries, trauma, developmental abnormalities, or pulpal and periapical disease.

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Contemporary management has shifted from a predominantly tissue-removal approach toward biologically based pulp therapy, emphasizing preservation of healthy pulp tissue whenever possible.

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Current recommendations distinguish treatment according to pulpal diagnosis, tooth restorability, root development, and the expected lifespan of the tooth.
For primary teeth, evidence increasingly supports indirect pulp treatment and calcium-silicate cement pulpotomy for appropriately selected vital teeth. In immature permanent teeth, maintaining pulp vitality is particularly important because it permits continued root maturation and apexogenesis.

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✅ Pulpal Diagnosis in Children
Accurate diagnosis is the foundation of pediatric endodontic treatment. Clinical history, symptoms, clinical examination, radiographic findings, and, when appropriate, pulp sensibility testing should be interpreted collectively.
In primary teeth, symptoms may be less predictable than in permanent teeth; therefore, clinical and radiographic findings should not be interpreted in isolation. Important findings include spontaneous or lingering pain, abnormal mobility, swelling, sinus tract formation, furcation radiolucency, pathological root resorption, and changes in the supporting tissues.

The principal diagnostic categories include:
▪️ Normal pulp
▪️ Reversible pulpitis
▪️ Symptomatic or asymptomatic irreversible pulpitis
▪️ Pulp necrosis
▪️ Previously treated or previously initiated therapy, when applicable
The treatment objective is not simply to eliminate pain but to control infection and preserve the tooth and surrounding tissues for as long as clinically appropriate.

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✅ Vital Pulp Therapy in Primary Teeth
For primary teeth with normal pulp or reversible pulpitis, contemporary management favors conservative approaches that preserve radicular pulp vitality.

Indirect Pulp Treatment
Indirect pulp treatment (IPT) is particularly useful for deep carious lesions when the pulp is considered vital and there are no clinical or radiographic findings indicating irreversible disease.
Selective caries removal reduces the probability of pulp exposure while allowing the remaining dentin and pulp-dentin complex to maintain biological activity. The 2024 AAPD guideline provides strong evidence supporting IPT for deeply carious primary teeth.

Pulpotomy
A pulpotomy removes the coronal pulp while preserving the radicular pulp. It remains an important treatment for vital primary teeth when caries removal results in exposure and the remaining radicular pulp is considered capable of healing.
Current evidence favors calcium-silicate materials, particularly mineral trioxide aggregate (MTA) and Biodentine, over several traditional pulpotomy medicaments. The AAPD 2024 guideline found higher 24-month success with IPT or calcium-silicate cement pulpotomy compared with several alternative approaches.
Consequently, calcium-silicate cement pulpotomy has become a major contemporary approach in primary-tooth vital pulp therapy.

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✅ Non-Vital Pulp Therapy in Primary Teeth
When a primary tooth presents with irreversible pulpitis or pulp necrosis, treatment generally requires removal of infected or necrotic tissue.

Pulpectomy
Pulpectomy involves removal of the pulp from the entire root canal system, followed by canal debridement, disinfection, and filling with a resorbable material.
Hand and rotary instrumentation can both be used. Evidence reviewed by the AAPD indicates that rotary instrumentation can substantially reduce instrumentation time without demonstrating a significant difference in filling quality or overall treatment success compared with manual instrumentation.
Irrigation is an essential component of canal disinfection. Sodium hypochlorite may be used at appropriate concentrations, but because of its tissue toxicity, extrusion beyond the root apex must be avoided. The final obturation material should be compatible with the physiologic resorption of primary roots.

Lesion Sterilization and Tissue Repair
Lesion sterilization and tissue repair (LSTR) is a non-instrumentation or minimally instrumented approach involving antimicrobial agents. It may have a role in selected primary teeth, particularly when conventional pulpectomy is unfavorable.
However, the evidence indicates that its application should be selective. LSTR may be advantageous in teeth with preoperative root resorption, whereas conventional pulpectomy performs better when roots remain intact. Close clinical and radiographic follow-up is therefore essential.

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✅ Vital Pulp Therapy in Immature Permanent Teeth
The management of immature permanent teeth differs fundamentally from that of primary teeth because preservation of vital pulp tissue can allow continued physiologic root development.

For permanent teeth with normal pulp or reversible pulpitis, contemporary options include:
▪️ Indirect pulp treatment
▪️ Direct pulp capping
▪️ Partial pulpotomy
▪️ Complete pulpotomy
The 2025 AAPD guideline indicates that selective caries removal is strongly recommended for deep caries in permanent teeth with normal pulp or reversible pulpitis. When pulp exposure occurs, calcium-silicate materials may be used for direct pulp capping, partial pulpotomy, or complete pulpotomy.

Partial Pulpotomy
Partial pulpotomy removes a limited portion of inflamed coronal pulp while preserving deeper healthy tissue. It is particularly relevant for traumatic exposures and selected carious exposures.
For traumatic exposures, the Cvek technique removes approximately 1–3 mm of superficial inflamed pulp, or more when necessary to reach healthy tissue. Hemostasis and a biologically compatible pulp-capping material are then required.

Complete Pulpotomy
Contemporary evidence has expanded the potential indications for complete pulpotomy in permanent teeth. In selected teeth with symptoms traditionally associated with irreversible pulpitis, complete pulpotomy may be considered when the pulp remains vital and adequate hemostasis can be achieved.
The 2025 AAPD guideline recommends calcium-silicate materials for vital pulp therapy and emphasizes appropriate hemostasis, with sodium hypochlorite recommended for pulp-hemostasis procedures.

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✅ Apexogenesis, Apexification, and Regenerative Endodontics
The primary biological objective in an immature permanent tooth with vital pulp is apexogenesis, allowing continued root development and thickening of the dentinal walls.
When the pulp is necrotic, conventional treatment may compromise further physiologic root development. Depending on the clinical situation, regenerative endodontic procedures or apexification may therefore be considered.
Regenerative approaches aim to promote continued root maturation and development of the apical region. Treatment selection should consider the stage of root development, infection control, restorability, and the long-term prognosis of the tooth. The current AAPD framework includes apexification and regenerative endodontics among the principal options for non-vital immature permanent teeth.

✅ Contemporary Materials and Techniques

Clinical Situation	Preferred Contemporary Approach	Key Consideration
Deep caries, vital primary tooth	Indirect pulp treatment	Selective caries removal and an effective coronal seal
Pulp exposure in a vital primary tooth	Calcium-silicate pulpotomy	MTA or another appropriate calcium-silicate cement
Necrotic primary tooth	Pulpectomy	Effective disinfection and resorbable obturation
Immature permanent tooth, vital pulp	Vital pulp therapy	Preserve vitality and promote apexogenesis
Traumatic pulp exposure	Partial pulpotomy	Remove inflamed superficial pulp and obtain hemostasis
Necrotic immature permanent tooth	Regenerative endodontics or apexification	Root maturity, infection control, and long-term prognosis

Table based on current AAPD recommendations and contemporary evidence.

✅ Technical Principles for Pediatric Endodontic Procedures
Successful pediatric endodontics depends not only on treatment selection but also on infection control, isolation, tissue preservation, and coronal sealing.

Isolation
Rubber dam isolation should be considered fundamental whenever endodontic treatment is performed. It improves moisture control, reduces microbial contamination, and protects the child from aspiration or ingestion of instruments and materials.

Magnification
Magnification can improve visualization of pulp tissue and facilitate assessment during vital pulp procedures. Its value is particularly relevant when determining the quality of the remaining pulp and controlling hemorrhage.

Hemostasis
In vital pulp therapy, controlled hemorrhage is an important clinical indicator. Persistent bleeding may indicate more extensive inflammation and influence the decision to remove additional pulp tissue or change the treatment approach.

Coronal Seal
A durable coronal restoration is essential because bacterial leakage can compromise otherwise successful pulp therapy. The definitive restoration should provide an effective seal and sufficient structural protection for the expected life of the tooth.

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💬 Discussion
The contemporary concept of pediatric endodontics is increasingly centered on biological preservation rather than routine removal of the entire pulp. This is particularly evident in the growing evidence supporting IPT and calcium-silicate pulpotomy in primary teeth and vital pulp therapy in immature permanent teeth.
The 2024 AAPD guideline found high-certainty evidence favoring IPT and calcium-silicate cement pulpotomy for deeply carious vital primary teeth. It also moved clinical practice further away from several traditional medicaments, including calcium hydroxide as a primary pulpotomy medicament and toward calcium-silicate materials.
At the same time, the 2025 AAPD guideline for permanent teeth reflects an important conceptual change: irreversible pulpitis does not automatically require complete pulpectomy or conventional root canal treatment when the pulp remains clinically viable and the tooth can be appropriately managed. Selected cases may benefit from partial or complete pulpotomy using calcium-silicate materials.
Nevertheless, evidence quality is not uniform across all pediatric endodontic interventions. Treatment decisions should therefore integrate the best available evidence with clinical diagnosis, tooth restorability, root development, infection status, patient cooperation, and long-term prognosis.

🎯 Clinical Recommendations
1. Prioritize biological diagnosis over symptoms alone. Combine history, clinical examination, radiographic findings, and pulp testing when appropriate.
2. Preserve vital pulp tissue whenever predictable healing is possible, particularly in immature permanent teeth where vitality supports continued root development.
3. Consider IPT as a first-line approach for appropriately selected deeply carious vital primary teeth, avoiding unnecessary pulp exposure.
4. When pulpotomy is indicated in a primary tooth, calcium-silicate cements such as MTA or Biodentine should be strongly considered based on current evidence.
5. For necrotic primary teeth, select pulpectomy or carefully indicated LSTR according to root resorption, infection, restorability, and prognosis.
6. In immature permanent teeth, consider partial or complete pulpotomy before conventional root canal treatment when the pulp remains potentially reparable and adequate hemostasis can be achieved.
7. Do not compromise apical development unnecessarily. Preservation of pulp vitality in immature permanent teeth should remain a major treatment objective.
8. Establish an effective coronal seal and schedule clinical and radiographic follow-up, because treatment success depends on both biological management and restoration quality.

✍️ Conclusion
Pediatric endodontics has evolved toward conservative, biologically oriented treatment. Current evidence supports indirect pulp treatment and calcium-silicate pulpotomy as important approaches for selected primary teeth, while vital pulp therapy has an increasingly important role in immature permanent teeth.
The fundamental principle is to match the intervention to the biological condition of the pulp rather than relying exclusively on historical treatment protocols. Accurate diagnosis, strict isolation, effective disinfection, appropriate biomaterials, durable coronal sealing, and systematic follow-up remain essential to achieving predictable outcomes.

📚 References

✔ American Academy of Pediatric Dentistry. (2026). Pulp therapy for primary and immature permanent teeth. In The Reference Manual of Pediatric Dentistry. American Academy of Pediatric Dentistry.
✔ Coll, J. A., Dhar, V., Chen, C.-Y., Crystal, Y. O., Guelmann, M., Marghalani, A. A., AlShamali, S., Xu, Z., Glickman, G. N., & Wedeward, R. (2024). Use of vital pulp therapies in primary teeth 2024. Pediatric Dentistry, 46(1), 13–26.
✔ Coll, J. A., Dhar, V., Chen, C.-Y., et al. (2023). Primary tooth vital pulp treatment interventions: Systematic review and meta-analyses. Pediatric Dentistry, 45(6), 474–546.
✔ Coll, J. A., Vargas, K., Marghalani, A. A., et al. (2020). Use of non-vital pulp therapies in primary teeth. Pediatric Dentistry, 42(5), 337–349.
✔ Coll, J. A., Dhar, V., Guelmann, M., Crystal, Y. O., Chen, C.-Y., Marghalani, A. A., Alshamali, S., Xu, Z., Ather, A., Sabeti, M., & Wedeward, R. (2025). Guideline for use of vital pulp therapy in permanent teeth. Pediatric Dentistry, 47(5), 299–311.
✔ Duggal, M., Gizani, S., Albadri, S., Krämer, N., Stratigaki, E., Tong, H. J., Seremidi, K., Kloukos, D., BaniHani, A., Santamaría, R. M., Hu, S., Maden, M., Amend, S., Boutsiouki, C., Bekes, K., Lygidakis, N., Frankenberger, R., Monteiro, J., Anttonen, V., ... Parekh, S. (2022). Best clinical practice guidance for treating deep carious lesions in primary teeth: An EAPD policy document. European Archives of Paediatric Dentistry, 23(5), 659–666. https://doi.org/10.1007/s40368-022-00718-6
✔ Da Silva, E. J. N. L., et al. (2024). Success of primary teeth pulpotomy using calcium silicate cements: A systematic review and meta-analysis of randomized clinical trials. Pediatric Dentistry, 46(6), 373–395.

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Can Ill-Fitting Dentures Increase Oral Cancer Risk?

Ill-fitting dentures can cause much more than discomfort. A denture that moves, rubs, or repeatedly injures the oral tissues may produce chronic irritation, sore spots, ulcers, and inflammation.

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But does this mean that poorly fitting dentures cause oral cancer?

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The answer is more nuanced. Research has found an association between chronic denture-related trauma and oral cancer, but current evidence does not establish that an ill-fitting denture directly causes cancer. In fact, systematic reviews have reached somewhat different conclusions regarding the strength of this relationship.
Therefore, the most important clinical issue is not to frighten denture wearers, but to avoid persistent trauma and never assume that a non-healing ulcer is simply a denture sore.

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✅ Can Ill-Fitting Dentures Cause Oral Cancer?
Not proven—but persistent mechanical irritation may be a contributing factor.
A 2014 meta-analysis reported a significant association between ill-fitting dentures and oral cancer, with an odds ratio of 3.90 (95% CI, 2.48–6.13).

Similarly, a systematic review and meta-analysis published in 2021 found an association between chronic mechanical irritation and oral squamous cell carcinoma (OSCC). The authors suggested that chronic irritation could act as a co-factor rather than an independent cause of cancer.
However, another systematic review specifically evaluating the quality of the evidence concluded that the available data were insufficient to establish chronic mechanical trauma as a true risk factor for oral cancer.

This distinction is important:
| An association does not prove that the denture itself causes cancer.
Oral cancer has multiple established risk factors, particularly tobacco use and heavy alcohol consumption.

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✅ Why Can a Poorly Fitting Denture Be a Problem?
A denture that does not fit properly can repeatedly press or rub against the same area of the oral mucosa.

Possible consequences include:
▪️ Repeated ulcers or sore spots
▪️ Chronic inflammation
▪️ Thickened or irritated tissue
▪️ Traumatic fibrous lesions
▪️ Difficulty eating or speaking
▪️ Reduced denture stability
▪️ Reduced quality of life
The tongue and cheek are among the areas that may be exposed to repeated mechanical irritation from dental prostheses.
Importantly, chronic trauma can also complicate cancer detection. An oral squamous cell carcinoma may initially be mistaken for a simple traumatic ulcer attributed to a denture. A published clinical report described a patient whose cancer diagnosis was delayed because an ulcer was initially considered denture-related trauma.

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✅ When Is a Denture-Related Ulcer Concerning?
Most traumatic lesions should improve after the source of irritation is corrected.

A persistent lesion deserves greater attention when it:
▪️ Does not heal after removing or correcting the source of trauma
▪️ Persists for approximately 2 weeks or longer
▪️ Becomes larger or more painful
▪️ Bleeds without an obvious cause
▪️ Feels firm or develops a lump
▪️ Appears as a persistent red, white, or mixed red-and-white lesion
▪️ Is associated with numbness or unexplained difficulty chewing or swallowing
The American Dental Association's current guidance emphasizes comprehensive clinical examination and states that persistent mucosal abnormalities require further evaluation; biopsy remains the reference standard for definitive diagnosis of potentially malignant disorders and oral squamous cell carcinoma.

Important clinical distinction

Situation	Appropriate Response
Denture causes an obvious sore spot	Identify and eliminate the mechanical cause.
Denture is loose or unstable	Evaluate fit, retention, and the need for adjustment or replacement.
Ulcer heals after correction	Continue routine follow-up.
Lesion persists or progresses	Further investigation or specialist referral.
Suspicious mucosal lesion	Biopsy or immediate specialist referral when indicated.

✅ Does Removing the Denture Eliminate Cancer Risk?
No.
If an ulcer is caused purely by mechanical trauma, eliminating the trauma should allow the tissue to heal. However, failure to heal does not prove that the denture caused the lesion, nor does removing the denture rule out cancer.
This is why a persistent lesion should not simply be monitored indefinitely after the denture is adjusted.
The ADA's 2026 living guideline emphasizes that clinical examination remains fundamental and that persistent or progressive abnormalities should proceed to appropriate diagnostic evaluation rather than relying on adjunctive screening technologies alone.

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💬 Discussion
The relationship between ill-fitting dentures and oral cancer remains scientifically debated.
Some observational studies and meta-analyses have identified a significant association between recurrent denture-related trauma and oral squamous cell carcinoma. For example, a case-control study found that recurrent sores caused by ill-fitting dentures were associated with oral cancer, even after adjustment for tobacco and alcohol exposure.
Nevertheless, systematic reviews have highlighted important limitations, including inconsistent definitions of chronic trauma and the observational nature of much of the available evidence. Consequently, it would be inappropriate to tell patients that "bad dentures cause cancer".
A more scientifically accurate message is:
Poorly fitting dentures should be corrected because they cause tissue injury and may be associated with oral cancer, but a direct causal relationship has not been definitively established.
For dentists, perhaps the greatest practical concern is diagnostic: do not automatically label a persistent ulcer as denture trauma.

✍️ Conclusion
Ill-fitting dentures do not have a proven direct causal relationship with oral cancer. However, persistent mechanical irritation is associated with oral mucosal injury, and some studies have reported an association with oral squamous cell carcinoma.
The safest approach is straightforward: correct the denture-related trauma, examine the mucosa carefully, and investigate any lesion that does not resolve or that shows suspicious features.
A denture sore that heals after correction is usually reassuring. A lesion that persists, enlarges, or changes deserves professional evaluation rather than repeated denture adjustments alone.

🎯 Clinical Recommendations
1. Check the fit of removable dentures regularly, particularly when patients report recurrent sore spots.
2. When a traumatic ulcer is identified, remove or correct the suspected mechanical cause and reassess healing.
3. Do not assume that every persistent denture-related ulcer is traumatic.
4. If a mucosal abnormality persists or progresses, arrange appropriate diagnostic evaluation or specialist referral rather than relying on visual appearance alone.
5. During routine denture reviews, perform a complete oral mucosal examination, not just a prosthetic fit assessment.
6. Counsel patients about established oral cancer risks, especially tobacco and heavy alcohol exposure, while avoiding the misleading statement that dentures themselves cause cancer.

📚 References

✔ Gupta, A. A., Kheur, S., Varadarajan, S., Parveen, S., Dewan, H., Alhazmi, Y. A., Raj, T. A., Testarelli, L., & Patil, S. (2021). Chronic mechanical irritation and oral squamous cell carcinoma: A systematic review and meta-analysis. Bosnian Journal of Basic Medical Sciences, 21(6), 647–658. https://doi.org/10.17305/bjbms.2021.5577
✔ Manoharan, S., Nagaraja, V., & Eslick, G. D. (2014). Ill-fitting dentures and oral cancer: A meta-analysis. Oral Oncology, 50(11), 1058–1061. https://doi.org/10.1016/j.oraloncology.2014.08.002
✔ Ribeiro, A. C. P., et al. (2019). Lack of association between denture trauma and loss of heterozygosity confronts the proposed pathologic role of chronic mucosal trauma in oral carcinogenesis. Journal of Oral Pathology & Medicine. https://doi.org/10.1111/jop.12846
✔ Villa, A., et al. (2021). Chronic mechanical trauma/irritation and oral carcinoma: A systematic review showing low evidence to support an association. Oral Diseases.
✔ American Dental Association. (2026). Cancer (head and neck): Oral cancer detection and clinical considerations.

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Amoxicillin-Clavulanate: When to Use It in Dentistry

Amoxicillin-clavulanate is a broad-spectrum β-lactam antibiotic used for selected odontogenic infections.

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Its combination of amoxicillin with clavulanic acid extends antibacterial activity against organisms that produce β-lactamases, making it useful when standard amoxicillin therapy is inadequate or broader antimicrobial coverage is clinically justified.

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However, broader coverage does not mean better routine treatment. Most dental infections should primarily be managed by definitive dental treatment, such as drainage, pulpotomy, pulpectomy, or root canal treatment, rather than systemic antibiotics alone.
Antibiotics are generally reserved for infections with systemic involvement, spreading infection, or situations in which definitive treatment cannot be provided immediately.

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✅ How Does Amoxicillin-Clavulanate Work?
Amoxicillin inhibits bacterial cell-wall synthesis. Clavulanic acid inhibits certain β-lactamases produced by bacteria, protecting amoxicillin from enzymatic degradation.
This combination therefore provides broader activity against some β-lactamase-producing oral bacteria than amoxicillin alone.
The clinical advantage must be balanced against greater antimicrobial exposure and a higher potential for gastrointestinal adverse effects compared with narrower-spectrum therapy.

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✅ When Should Amoxicillin-Clavulanate Be Considered?
The most important indication in routine dental practice is failure of appropriate first-line therapy.
For an immunocompetent adult with an odontogenic infection for which antibiotics are indicated, the ADA guideline recommends amoxicillin 500 mg three times daily for 3–7 days as a first-line option. If the patient does not improve or the infection progresses, therapy can be broadened by either adding metronidazole or switching to amoxicillin-clavulanate 500/125 mg three times daily for 7 days.
Clinical situations

Clinical situation	Role of amoxicillin-clavulanate
Localized infection without systemic involvement	Usually not indicated. Prioritize definitive dental treatment and drainage when appropriate.
Odontogenic infection with systemic involvement	An antibiotic may be indicated as an adjunct to urgent dental treatment. Amoxicillin is generally an appropriate first-line option.
Inadequate response to amoxicillin	Appropriate consideration. ADA guidance supports switching to amoxicillin-clavulanate or adding metronidazole.
Progressive or spreading odontogenic infection	May be appropriate depending on severity, timing of source control, and local guidelines. Severe infection may require urgent hospital or specialist management.
Routine dental procedure or uncomplicated dental pain	Not indicated. Antibiotics should not be used simply to treat pain or prevent routine postoperative complications.

✅ Amoxicillin vs. Amoxicillin-Clavulanate
Amoxicillin remains an important first-line choice when systemic antibiotic therapy is indicated in many odontogenic infections. The addition of clavulanate should be based on the clinical situation rather than used automatically.

Feature	Amoxicillin	Amoxicillin-Clavulanate
Spectrum	Narrower	Broader, including some β-lactamase-producing organisms
Typical role	First-line therapy when antibiotics are indicated	Broader therapy when clinically justified, particularly after inadequate response
Antimicrobial stewardship	Generally preferred when adequate	Should not replace narrower therapy without a clinical reason
Adverse effects	Generally well tolerated	More gastrointestinal adverse effects may occur

✅ Why Is Clavulanic Acid Important?
Some bacteria associated with odontogenic infections can produce β-lactamases, enzymes capable of inactivating certain β-lactam antibiotics. Clavulanic acid inhibits several of these enzymes and can therefore restore or extend the activity of amoxicillin against susceptible organisms.
This pharmacological advantage explains why amoxicillin-clavulanate may be useful after inadequate clinical response to amoxicillin. Nevertheless, antimicrobial susceptibility varies geographically, and treatment decisions should consider the clinical response, severity of infection, patient factors, and local antimicrobial guidance.

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✅ Evidence From Odontogenic Infections
Clinical evidence supports the effectiveness of amoxicillin-clavulanate in acute odontogenic infections. In a randomized study involving 472 patients, amoxicillin-clavulanate 875/125 mg twice daily was noninferior to clindamycin for clinical success, with overall success rates of 88.2% and 89.7%, respectively. Most adverse events were mild to moderate.
This evidence supports its clinical efficacy but does not establish amoxicillin-clavulanate as the preferred first-line antibiotic for every dental infection. Current antibiotic-stewardship principles favor the narrowest effective antimicrobial regimen.

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✅ When Should It Be Avoided?
Amoxicillin-clavulanate should not be prescribed simply because an infection is dental in origin.

It is generally inappropriate for:
▪️ Irreversible pulpitis without systemic infection
▪️ Symptomatic apical periodontitis without systemic involvement
▪️ Localized conditions that can be adequately treated with drainage or definitive dental therapy
▪️ Routine dental procedures without a specific indication for antibiotic prophylaxis
▪️ Situations in which the patient has a clinically significant penicillin allergy
The ADA specifically recommends against routine systemic antibiotics for most pulpal and periapical conditions and emphasizes definitive dental treatment as the primary intervention.

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✅ Important Safety Considerations
Before prescribing, clinicians should evaluate:

▪️ History of penicillin or β-lactam allergy
▪️ Previous antibiotic-associated adverse reactions
▪️ Hepatic disease or previous cholestatic reactions associated with amoxicillin-clavulanate
▪️ Renal function when clinically relevant
▪️ Current medications and potential interactions
▪️ Local antimicrobial resistance patterns
▪️ The possibility of a deep-space infection requiring urgent referral
Common adverse effects include diarrhea, nausea, and gastrointestinal discomfort. Unnecessary broad-spectrum antibiotic exposure also contributes to antimicrobial resistance and disruption of the normal microbiota.

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💬 Discussion
The clinical value of amoxicillin-clavulanate lies primarily in its ability to provide broader β-lactam coverage when narrower therapy is insufficient or when the clinical circumstances justify broader treatment.
Current evidence-based dental guidance emphasizes that antibiotic selection should follow, rather than replace, source control. Drainage, endodontic treatment, extraction, or other definitive procedures remain fundamental to managing odontogenic infection.
The decision to use amoxicillin-clavulanate should therefore be based on three questions: Is an antibiotic actually indicated? Is amoxicillin an adequate first-line choice? Has the patient failed to improve or does the infection justify broader coverage?
This approach is consistent with modern antibiotic stewardship, which seeks to achieve clinical efficacy while minimizing unnecessary broad-spectrum antimicrobial exposure.

✍️ Conclusion
Amoxicillin-clavulanate is not routinely the first antibiotic for dental infections. Its principal role is as a broader-spectrum option when an odontogenic infection requires systemic antibiotics and first-line amoxicillin is ineffective, or when the clinical characteristics of the infection warrant broader antimicrobial coverage.
Appropriate use requires simultaneous attention to source control, infection severity, allergy history, clinical response, and antimicrobial stewardship.

🎯 Clinical Recommendations
1. Do not prescribe amoxicillin-clavulanate for dental pain alone.
2. When systemic antibiotics are indicated, amoxicillin is generally an appropriate first-line option for immunocompetent adults without penicillin allergy.
3. Consider amoxicillin-clavulanate after inadequate response to appropriate first-line therapy, consistent with current ADA guidance.
4. Reassess the patient within approximately 3 days when antibiotics are prescribed.
5. Do not allow antibiotic therapy to delay drainage or definitive dental treatment.
6. Escalate urgently when there are signs of deep-space infection, airway compromise, severe systemic involvement, or rapidly progressive swelling.
7. Use the shortest clinically appropriate course and discontinue therapy when clinically indicated according to the applicable guideline.

📚 References

✔ American Dental Association. (2023). Antibiotic stewardship. ADA. https://www.ada.org/resources/ada-library/oral-health-topics/antibiotic-stewardship
✔ 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. M., Suda, K. J., Swan, J., Treister, N. S., & Tampi, M. P. (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. The Journal of the American Dental Association, 150(11), 906–921.e12. https://doi.org/10.1016/j.adaj.2019.08.020
✔ Segura-Egea, J. J., Gould, K., Şen, B. H., Jonasson, P., Cotti, E., Mazzoni, A., Sunay, H., Tjäderhane, L., & Dummer, P. M. H. (2018). European Society of Endodontology position statement: The use of antibiotics in endodontics. International Endodontic Journal, 51(1), 20–25. https://doi.org/10.1111/iej.12781
✔ Tancawan, A. L., Pato, M. N., Abidin, K. Z., Asari, A. S. M., Thong, T. X., Kochhar, P., Muganurmath, C., Twynholm, M., & Barker, K. (2015). Amoxicillin/clavulanic acid for the treatment of odontogenic infections: A randomised study comparing efficacy and tolerability versus clindamycin. International Journal of Dentistry, 2015, Article 472470. https://doi.org/10.1155/2015/472470

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Dexamethasone Use in Periodontal Surgery: Pros & Cons

Dexamethasone use in periodontal surgery has been investigated as a perioperative strategy to reduce the inflammatory response associated with surgical manipulation of periodontal tissues.

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Because postoperative pain and edema can affect comfort, mastication, and recovery, corticosteroids may provide an adjunctive benefit when appropriately selected.

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Current evidence suggests that perioperative dexamethasone can reduce postoperative pain and swelling, particularly during the first several days after periodontal flap surgery.
However, its benefits should be balanced against patient-specific contraindications, potential adverse effects, and the limited number of high-quality periodontal studies.

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✅ How Dexamethasone Works in Periodontal Surgery
Dexamethasone is a potent glucocorticoid with anti-inflammatory activity. It suppresses multiple inflammatory pathways, including the production of prostaglandins and other mediators involved in vascular permeability, tissue edema, and postoperative pain.
In periodontal surgery, this mechanism may attenuate the acute inflammatory response produced by flap elevation, tissue manipulation, and surgical trauma.
Importantly, dexamethasone is an adjunct to surgical and analgesic management, not a substitute for atraumatic surgical technique or appropriate postoperative analgesia.

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✅ Benefits of Dexamethasone in Periodontal Surgery

1. Reduction of postoperative pain
Randomized clinical trials have demonstrated a reduction in postoperative pain following periodontal flap surgery when dexamethasone is administered perioperatively.
A randomized trial involving 60 patients undergoing open-flap debridement found that an 8-mg preoperative dose of dexamethasone provided greater pain control and reduced the need for rescue acetaminophen compared with placebo.
More recently, a randomized crossover trial found that 8 mg of intravenous dexamethasone administered before periodontal flap surgery significantly reduced pain during the first 72 hours compared with placebo.

2. Reduction of postoperative swelling
The anti-inflammatory effect of dexamethasone may also reduce postoperative edema.
In the 2022 randomized trial, intravenous dexamethasone was associated with significantly less swelling during several postoperative assessment periods, including the early postoperative phase.
A 2024 randomized clinical study also reported less swelling on the first postoperative day after submucosal administration of 8 mg dexamethasone during periodontal flap surgery.

3. Potential improvement in early postoperative function
Reduction of inflammatory edema may facilitate early oral function. The 2024 submucosal study reported improved chewing efficiency and less reduction in mouth opening during the early postoperative period. However, these findings should be interpreted cautiously because the study included only 25 patients.

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✅ Routes and Timing of Administration
Dexamethasone has been studied through several administration routes, including oral, intravenous, and submucosal administration.

Approach	Evidence in Periodontal Surgery	Main Consideration
Preoperative oral	Evidence of reduced postoperative pain	Convenient; evidence remains limited
Intravenous	Reduced pain and swelling in randomized clinical trials	Useful when IV access is already established
Submucosal	Recent evidence suggests reduced pain and swelling	Avoids the need for IV access
Repeated postoperative dosing	Less consistently studied	Greater exposure is not necessarily associated with greater benefit

Factor	Clinical implication
Timing	Preoperative or perioperative administration is the approach most consistently investigated.
Dose	Studies have commonly evaluated single doses of 4–8 mg, but no universally established periodontal surgery regimen exists.
Route	IV and submucosal administration have demonstrated clinical effects; the optimal route remains uncertain.

The evidence should therefore not be interpreted as establishing 8 mg as a universal standard dose. The 8-mg regimen has been studied in clinical trials, but patient characteristics, surgical extent, route of administration, and local prescribing regulations must be considered.

✅ Limitations and Safety Considerations

1. Evidence remains limited
A 2024 systematic review identified only six randomized clinical trials involving 250 participants evaluating preemptive steroidal and nonsteroidal analgesia in periodontal surgery. The authors noted substantial methodological limitations, including risk of bias and heterogeneity in drugs and doses.
Consequently, dexamethasone should be regarded as a selective adjunct rather than routine therapy for every periodontal surgical procedure.

2. Hyperglycemia
Systemic corticosteroids can transiently increase blood glucose concentrations. This is particularly relevant in patients with diabetes or impaired glucose regulation.
Patient-specific risk assessment is therefore important before administration, especially when systemic corticosteroids are being considered.

3. Infection considerations
Corticosteroids suppress immune responses and can potentially exacerbate or mask infection. Current prescribing information warns that corticosteroids may reduce resistance to infection and obscure clinical signs of infection.
This does not mean that a single perioperative dose inevitably causes infection. Indeed, a large Cochrane review of perioperative dexamethasone in surgical patients found no evidence of increased postoperative wound infection with a single perioperative steroid exposure.
Nevertheless, dexamethasone should not be used to mask an inadequately controlled infection or as a substitute for appropriate antimicrobial or surgical management.

4. Not a replacement for conventional analgesia
Dexamethasone primarily modifies the inflammatory component of postoperative morbidity. It should not automatically replace evidence-based analgesic therapy.
Current dental pain guidelines support NSAIDs, alone or combined with acetaminophen, as first-line pharmacologic therapy for acute dental pain when not contraindicated.

5. Limited evidence regarding long-term periodontal outcomes
Most studies evaluate short-term outcomes such as pain, swelling, trismus, and analgesic consumption. There is insufficient evidence to conclude that perioperative dexamethasone improves long-term periodontal healing, attachment gain, or regenerative outcomes.

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💬 Discussion
The current evidence supports a potential role for perioperative dexamethasone as an adjunct in periodontal surgery, particularly when postoperative inflammation is expected to be clinically significant.
The strongest periodontal evidence concerns reduction of early postoperative pain and swelling. Both intravenous and submucosal administration have demonstrated beneficial effects in randomized trials, while a recent systematic review supports the potential effectiveness of preemptive dexamethasone for postoperative pain.
However, the evidence base remains relatively small and heterogeneous. The 2024 systematic review specifically highlighted methodological limitations and the need for additional well-designed randomized trials.
Therefore, the clinical decision should be individualized rather than protocol-driven. Dexamethasone may be particularly reasonable when substantial postoperative inflammation is anticipated, while routine administration for uncomplicated periodontal procedures offers less clearly established incremental benefit.

✍️ Conclusion
Dexamethasone can reduce postoperative pain and swelling following periodontal surgery, with evidence supporting both systemic and local administration. Its anti-inflammatory effect makes it a potentially useful perioperative adjunct, particularly for procedures associated with greater tissue trauma.
Nevertheless, dexamethasone is not universally indicated. The relatively limited periodontal evidence, potential systemic effects, glucose elevation, infection-related considerations, and absence of demonstrated long-term periodontal benefits support a selective, patient-centered approach.
The most appropriate use is therefore as an adjunct to atraumatic surgical technique and evidence-based analgesia, rather than as routine medication for all periodontal surgical patients.

🎯 Clinical Recommendations
▪️ Consider perioperative dexamethasone selectively when postoperative pain or edema is expected to be clinically significant.
▪️ Do not interpret the commonly studied 8-mg dose as a universal periodontal protocol; dosing should be individualized according to the clinical situation and route of administration.
▪️ Consider submucosal administration when an IV route is unnecessary; current evidence suggests it can provide postoperative benefits without clear superiority of IV administration for pain or analgesic consumption.
▪️ Evaluate diabetes, infection, immunosuppression, corticosteroid exposure, and other relevant medical conditions before prescribing.
▪️ Maintain conventional evidence-based analgesia; dexamethasone should generally be considered an adjunct rather than a replacement for NSAID-based analgesic strategies when these are appropriate.
▪️ Avoid routine corticosteroid use when the expected inflammatory burden is low and the potential benefit is unlikely to justify systemic exposure.
▪️ Explain to patients that the principal expected benefit is short-term reduction of postoperative inflammatory symptoms, not improvement of long-term periodontal healing.

📚 References

✔ Altindal, D., Alsafadi, A., Alshujaa, B., Talmac, A. C., Ege, B., Calisir, M., & Alpaslan, N. Z. (2024). Effect of submucosal dexamethasone on postoperative pain, swelling and trismus after periodontal surgery: A randomized clinical study. Clinical Oral Investigations, 28(12), 681. https://doi.org/10.1007/s00784-024-06076-5
✔ Carrasco-Labra, A., Polk, D. E., Urquhart, O., Aghaloo, T., Claytor, J. W., Jr., Dhar, V., Dionne, R. A., Espinoza, L., Gordon, S. M., Hersh, E. V., Law, A. S., Li, B. S.-K., Schwartz, P. J., Suda, K. J., Turturro, M. A., Wright, M. L., Dawson, T., Miroshnychenko, A., Pahlke, S., Pilcher, L., Shirey, M., Tampi, M., & Moore, P. A. (2024). Evidence-based clinical practice guideline for the pharmacologic management of acute dental pain in adolescents, adults, and older adults. Journal of the American Dental Association, 155(2), 102–117.e9. https://doi.org/10.1016/j.adaj.2023.10.009
✔ Lages, L. P. de D., Bergamaschi, C. de C., Lopes, L. C., da Frota, E. G., Silva, M. T., Monte, T. L., & Motta, R. H. L. (2024). Preemptive oral analgesia with steroidal and nonsteroidal anti-inflammatory drugs in periodontal surgery: A systematic review. Frontiers in Pharmacology, 15, 1385401. https://doi.org/10.3389/fphar.2024.1385401
✔ Vieth, M. P., Deas, D. E., Palaiologou, A. A., Diogenes, A., Mader, M. J., & Mealey, B. L. (2022). Effect of intravenous dexamethasone on postoperative pain and swelling following periodontal flap surgery: A randomized controlled trial of patient-centered outcomes. Journal of Periodontology, 93(2), 237–245. https://doi.org/10.1002/JPER.21-0153
✔ Wagner, J. C., Johnson, T. M., & Gilbert, W. A. (2022). Should periodontists prescribe postoperative oral corticosteroids to control pain and swelling? A systematic review. Clinical Advances in Periodontics, 12(2), 134–142. https://doi.org/10.1002/cap.10169
✔ Sauerland, S., Nagelschmidt, M., Mallmann, P., & Neugebauer, E. A. M. (2019). Adverse side-effects of dexamethasone in surgical patients—An abridged Cochrane systematic review. Anaesthesia, 74(8), 1013–1020. https://doi.org/10.1111/anae.14610
✔ Green, V. G., Polk, D. E., Turturro, M. A., Moore, P. A., & Carrasco-Labra, A. (2025). Evidence-based clinical practice guidelines for the management of acute dental pain. American Journal of Emergency Medicine, 89, 247–253. https://doi.org/10.1016/j.ajem.2024.12.054

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