Tooth Extraction Re Bleeding Again Help

Cochrane Database Syst Rev. 2018 Mar; 2018(iii): CD011930.

Interventions for treating mail service‐extraction haemorrhage

Monitoring Editor: Sumanth Kumbargere Nagraj, Eachempati Prashanti, Himanshi Aggarwal, Ashok Lingappa, Murugan S Muthu, Salian Kiran Kumar Krishanappa, Haszelini Hassan, and Cochrane Oral Wellness Group

Kinesthesia of Dentistry, Melaka‐Manipal Medical College, Manipal University of Higher Education (MAHE), Manipal, Section of Oral Medicine and Oral Radiology, Jalan Batu Hampar, Bukit Baru, MelakaMalaysia, 75150

Kinesthesia of Dentistry, Melaka‐Manipal Medical Higher, (Manipal Academy of Higher Instruction), Section of Prosthodontics, Jalan Batu Hampar, Bukit Baru, MelakaMalaysia, 75150

Rex George's Medical University, Department of Prosthodontics, KGMU Campus, LucknowUttar PradeshIndia

Bapuji Dental Higher and Hospital, Oral Medicine & Radiology, DavangereKarnatakaIndia

Kinesthesia of Dental Sciences, Sri Ramachandra University, Paediatric Dentistry, 2C Akme Park, Pedo Planet, Paediatric Dental Centre, OPP S&S Ability LTD,, PorurChennaiIndia, 600116

Faculty of Dentistry, Melaka Manipal Medical College (Manipal Academy of College Education), Department of Prosthodontics, Jalan Batu Hampar, MelakaMalaysia, 75150

International Islamic University Malaysia, Department of Oral Maxillofacial Surgery & Oral Diagnosis, Kulliyyah of Dentistry, Kuala LumpurMalaysia

Abstract

Background

Post‐extraction bleeding (PEB) is a recognised, frequently encountered complication in dental practice, which is defined every bit bleeding that continues beyond viii to 12 hours after dental extraction. The incidence of post‐extraction bleeding varies from 0% to 26%. If mail service‐extraction bleeding is not managed, complications can range from soft tissue haematomas to severe blood loss. Local causes of haemorrhage include soft tissue and bone haemorrhage. Systemic causes include platelet problems, coagulation disorders or excessive fibrinolysis, and inherited or acquired problems (medication induced). There is a broad array of techniques suggested for the treatment of post‐extraction bleeding, which include interventions aimed at both local and systemic causes. This is an update of a review published in June 2016.

Objectives

To appraise the furnishings of interventions for treating unlike types of post‐extraction haemorrhage.

Search methods

Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health'due south Trials Register (to 24 Jan 2018), the Cochrane Central Annals of Controlled Trials (CENTRAL) (the Cochrane Library, 2017, Outcome 12), MEDLINE Ovid (1946 to 24 Jan 2018), Embase Ovid (1 May 2015 to 24 Jan 2018) and CINAHL EBSCO (1937 to 24 Jan 2018). The US National Institutes of Health Trials Registry (ClinicalTrials.gov) and the World Health Organisation International Clinical Trials Registry Platform were searched for ongoing trials. We searched the reference lists of relevant systematic reviews.

Pick criteria

We considered randomised controlled trials (RCTs) that evaluated any intervention for treating PEB, with male or female participants of any age, regardless of blazon of teeth (inductive or posterior, mandibular or maxillary). Trials could compare i type of intervention with another, with placebo, or with no treatment.

Information collection and assay

Three pairs of review authors independently screened search records. We obtained full papers for potentially relevant trials. If data had been extracted, we would have followed the methods described in the Cochrane Handbook for Systematic Reviews of Interventions for the statistical analysis.

Main results

We did non detect any randomised controlled trial suitable for inclusion in this review.

Authors' conclusions

We were unable to identify any reports of randomised controlled trials that evaluated the furnishings of different interventions for the treatment of post‐extraction bleeding. In view of the lack of reliable evidence on this topic, clinicians must apply their clinical experience to determine the about appropriate means of treating this status, depending on patient‐related factors. In that location is a need for well designed and appropriately conducted clinical trials on this topic, which accommodate to the CONSORT statement (www.consort‐argument.org/).

Manifestly language summary

Interventions for managing bleeding afterward tooth removal

Review question

Nosotros conducted this review to assess different interventions for treating bleeding after tooth removal.

Background

Afterwards tooth extraction, it is normal for the area to bleed and and then clot, by and large within a few minutes. Information technology is abnormal if bleeding continues without clot formation, or lasts beyond 8 to 12 hours; this is known as mail service‐extraction bleeding (PEB). Such bleeding incidents can cause distress for patients, who might need emergency dental consultations and interventions. The causes of PEB tin exist local, a systemic disease, or a medication. To command this bleeding, many local and systemic methods have been practised, based on the clinician's expertise. To inform clinicians almost the best treatment, show is needed from studies where people have been randomly allocated to 1 of at least two unlike groups, which receive different treatments, or no treatment (i.eastward. 'randomised controlled trials' or RCTs).

Report characteristics

Authors working with Cochrane Oral Health updated this review of RCTs that appraise interventions to treat haemorrhage after molar removal. The original review was published in June 2016. For this version, we searched the medical and dental literature to 24 January 2018. Nosotros constitute no RCTs that met the inclusion criteria for our review.

Primal results and quality of the show

This review revealed that there is no RCT prove for the effectiveness of whatsoever bachelor intervention for treating postal service‐extraction haemorrhage. Loftier quality RCTs are needed to assist clinicians and patients make informed choices almost treatment options.

Summary of findings

Background

Description of the status

Tooth removal, or extraction, is one of the most common invasive oral surgical procedures carried out in routine dental practice (Van Galen 2014), and post‐extraction bleeding is a recognised, ofttimes encountered complication (McCormick 2014a). Immediately following the removal of a tooth, haemorrhage or oozing commonly occurs. This bleeding can be easily controlled in near cases (Amer 2014), and near completely stops inside 8 hours of extraction. However, sometimes information technology may continue, resulting in a life‐threatening situation (Funayama 1994). It is of import to distinguish between active bleeding from the surgical site and oozing. The active bleeding complexity is usually termed 'post‐extraction haemorrhage' (PEB) or 'mail‐operative haemorrhage afterward extraction'. Amer 2014 has described PEB every bit "evidence of bleeding beyond the pressure pack". Lockhart 2003 has provided four criteria to define PEB, namely that information technology:

continues across 12 hours;
causes the patient to call or return to the dental practitioner, or go to the accident and emergency department;
results in the development of a big haematoma or ecchymosis within the oral soft tissues; or
requires a blood transfusion, hospitalisation, or both.

The rate of postoperative bleeding after extraction of mandibular third molars is 0.6% and after extraction of maxillary third molars is 0.iv% (Chiapasco 1993). Jensen 1974 reviewed 103 cases of postoperative prolonged haemorrhage after oral surgery and reported that 75% of PEB occurred inside viii hours of the surgery, and only four patients had coagulation deficiencies. He also reported that postoperative prolonged haemorrhage from the mandibular molars is more mutual (80%) than haemorrhage from the maxillary molars (twenty%) because of the highly vascular flooring of the mouth. Wells 2000 reported that the risk of prolonged bleeding was 0.2% to 1.4% in cases of third molar removal surgery. Iwabuchi 2014 reported ii.77% clinically‐pregnant PEB in patients receiving warfarin therapy, and 0.39% in non‐warfarin groups, regardless of the type of teeth (95% CI 0.65% to iv.10%). Kataoka 2016 reported that the incidence of PEB ranged from 0 to 26% in their accomplice study. Yagyuu 2017 reported that the take chances of post‐extraction bleeding was similar for patients on directly oral anticoagulants and Vitamin K antagonist extractions.

Post‐extraction bleeding has been attributed to various factors that can be broadly classified every bit local and systemic (McDonnell 2013; Van Galen 2014). Post‐extraction bleeding can be caused locally, from soft tissue or bone bleeding. Soft tissue bleeding can be due to traumatic extraction, leading to laceration of blood vessels (arterial, venous or capillary). Bone or osseous bleeding tin can exist from either the food canals or from the central vessels. Inflammation at the site of extraction, the presence of infection, traumatic extraction, and failure of the patient to follow post‐extraction instructions take also been associated with PEB. Systemic factors include platelet bug, coagulation disorders or excessive fibrinolysis, and inherited or acquired problems (medication induced).

Post‐extraction bleeding tin can be categorised as primary prolonged bleeding, intermediate or reactionary prolonged bleeding, and secondary prolonged bleeding. Master prolonged bleeding occurs during the extraction process, and may be due to traumatic extraction leading to laceration of blood vessels, infections, such as periapical granuloma, or injury to the os. Patients with chief prolonged bleeding present with their mouth actively filling with blood immediately later on removing the haemostatic dressing. Reactionary haemorrhage occurs a few hours post‐extraction and is more than common in patients with systemic disorders or patients on anticoagulant therapy. Secondary bleeding (liver clots) usually occurs 7 to x days after extraction, and is a complication rarely encountered in dental practice (Malik 2008; Tabular array two). Abdullah 2014 has classified PEB as mild (oozing), moderate (haemorrhage persisting on the second day of extraction), and severe (whatever bleeding that needed hospitalisation).

ane

Types of haemorrhage subsequently dental extractions

Normal bleeding	Post‐extraction haemorrhage
Normal bleeding	Primary	Reactionary	Secondary
Usually persists for up to one-half an hour Oozing and claret tinged saliva for up to 8 hours Controlled past pressure pack	Occurs during and immediately after extraction Typically presents as blood filling up the mouth Ordinarily due to infection or trauma to blood vessels Often controlled by local techniques like pressure packs, haemostatic agents, etc	Begins 2 to three hours post extraction, subsequently the vasoconstrictor effect of local anaesthesia wears off Usually due to underlying systemic conditions such as bleeding or clotting disorders Not controlled past local measures and may require systemic interventions	Usually begins 7 to 10 days post extraction Mainly due to secondary infection Rare in dental extractions, compared to the other two types of post‐extraction bleeding

In this review, we considered all the definitions and classifications described in a higher place as PEB.

Description of the intervention

The treatment of bleeding complications post-obit a dental extraction is an essential skill for the dental practitioner (McCormick 2014b). Clinical determination making on how to control PEB depends on multiple factors, including the surgical location and site of bleeding, wound size, extent of haemorrhage, accessibility of the haemorrhage site, and timing of bleeding (Howe 2013). Furthermore, the option of an intervention strategy to accomplish haemostasis (blood clot formation at the site of vessel injury (Traver 2006)) also depends upon whether the patient is taking any medication or is suffering from any systemic disease, such as cirrhosis, that can affect bleeding and coagulation (McCormick 2014b).

Interventions for treating PEB can be broadly categorised into local and systemic interventions. Local interventions can exist further subdivided into surgical interventions, non‐surgical interventions and a combination of both.

Local interventions

Surgical intervention mainly involves suturing the extraction or bleeding site (Bajkin 2014; Van Galen 2014).
Non‐surgical haemostatic measures, or styptics, encompass an array of pharmacotherapies, sealants, adhesives, absorbable agents, biologics, and combination products (Howe 2013). Common haemostatic agents used in oral surgery in extraction sites include the following (Al‐Belasy 2003; Mingarro‐de‐León A 2014): local pressure application with gauze, oxidised cellulose (Abdullah 2014), gel foam, thrombin, collagen fleeces (Baumann 2009), cyanoacrylate glue, acrylic or surgical splints (Anderson 2013), local antifibrinolytic solutions, such as tranexamic acid mouthwash (Carter 2003), fibrin glue or adhesive (Cocero 2015), resorbable gelatin sponge, collagen sponge, gauze soaked with tranexamic acrid (Perdigão 2012), chlorhexidine bio‐adhesive gel, calcium alginate (Scarano 2014), Haemocoagulase (Joshi 2014), Ankaferd Blood Stopper (Amer 2014), green tea extract (Soltani 2014), Chitosan‐based dressings (Pippi 2015; Sharma 2017), and bone wax.
Various combinations of surgical and non‐surgical interventions accept also been used, such every bit tranexamic acrid mouthwash along with gelatin sponge and sutures, and fibrin glue with collagen fleece and sutures (Al‐Belasy 2003).

Systemic interventions

Systemic interventions are specially important in patients who have an associated systemic cause for haemorrhage. The part of local haemostatics is limited in these cases, because their apply results in only temporary abeyance of bleeding (Auluck 2004). Systemic interventions include administration of fresh frozen plasma (FFP), platelets, or both (Cocero 2015), factor replacement therapy, using recombinant or plasma‐derived anti‐haemophilic factor A (FVIII) or anti‐haemophilic factor B or Christmas factor (FIX) in the instance of haemophilia, and plasma‐derived Von Willebrand cistron (VWF)/FVIII concentrates in the case of Von Willebrand disease (Anderson 2013), intranasal desmopressin (Stanca 2010), intravenous synthetic vasopressin (Minkin 2015), oral or intravenous tranexamic acid (Morimoto 2004), oral or intravenous epsilon amino‐d‐caproic acrid (Van Galen 2014). In that location are contradictory opinions on discontinuation of antithrombotic medications; for example, Aframian 2007 suggests the discontinuation of these medications, whereas Wahl 2016 suggests these medications for dental procedures should not be interrupted, every bit the prognosis of potential postal service‐extraction haemorrhage that could consequence from antithrombotic continuation is better than the prognosis of a potential stroke or heart attack that could follow antithrombotic interruption.

How the intervention might work

Haemostasis, or command of haemorrhage, in the mouth is dependent on the dynamic balance between fibrin formation and resolution and is influenced by the external environment, which contains both plasminogen and plasminogen activators (Carter 2003). It is a circuitous interaction between platelets, plasma proteins, and coagulation and fibrinolytic pathways. The clotting pour involves the sequential activation of proenzymes in a stepwise response, which ultimately provides local generation of fibrin lattices that reinforce the platelet plug (Traver 2006). The coagulation process consists of 3 primary phases: initiation, amplification, and propagation (Figure 1; Glick 2013). The initiation phase begins with injury to the endothelium and tissue factor release, ultimately leading to thrombin formation. Platelet aggregation and activation occur during the amplification phase (Glick 2013), and provide the initial haemostatic response (Traver 2006). Finally, fibrin formation and stabilisation of the platelet clot occur during the propagation phase (Glick 2013).

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Different phases of coagulation

Different interventions to control PEB basically interfere with the clotting pour at unlike levels, resulting in cessation of bleeding. The mechanism of activity of various interventions can exist broadly summarised, based on the different phases.

Initiation phase: force per unit area packs, suture, bone wax, cellulose, styptics, gel foam, tranexamic acid, aminocaproic acid, cryoprecipitate, desmopressin (DDAVP), factor VIII concentrate and prothrombin complex concentrate (PCC) act at different stages of this phase.
Amplification phase: ethamsylate, haemostatic collagen and Actcell^® act during this phase.
Propagation stage: cryoprecipitate and recombinant gene (VIIa) act during this phase.

Local interventions piece of work either mechanically or by augmenting the coagulation cascade. Haemostatic agents deed to end bleeding by causing vasoconstriction or promoting platelet aggregation, whereas tissue adhesives or sealants bind to and close defects in tissue (Traver 2006). Systemic interventions piece of work by inhibiting fibrinolysis or promoting coagulation (Van Galen 2014).

Why it is important to do this review

Cochrane Oral Health undertook an extensive prioritisation exercise in 2014 to place a cadre portfolio of titles that were the most clinically important ones to maintain in the Cochrane Library (Worthington 2015). This review was identified as a priority title by the oral and maxillofacial surgery expert panel (Cochrane OHG priority review portfolio).

A broad array of techniques are suggested for the handling of PEB and different guidelines have been published (Higginson 2007; University of Cambridge). Until our commencement version of this review in June 2016, at that place had been no Cochrane review to summarise the effects of the various interventions available to treat PEB and provide testify to guide clinical dental do. Considering the different complex interventions addressing diverse outcome measures, it seems important to endeavour to describe the components of interventions and to place effective intervention strategies. A systematic review can inform the implementation of different approaches and trigger the development of new interventions on the basis of current all-time evidence. A systematic review on this topic is too needed since interventions of questionable effectiveness and unclear consequences might be in use.

Objectives

To appraise the effects of interventions for treating different types of post‐extraction bleeding.

Methods

Criteria for because studies for this review

Types of studies

We considered randomised controlled trials (RCTs) evaluating any intervention for treating post‐extraction bleeding (PEB). We excluded quasi‐RCTs, cantankerous‐over trials and preventive trials. Nosotros had planned to include split‐mouth studies, provided in that location was no possibility of contamination. Split up‐mouth design is one of the self‐controlled study designs that is unique to dentistry. The design is characterised by subdividing the mouth of the bailiwick into homogeneous within‐patient experimental units such as quadrants, sextants, contralateral or ipsilateral quadrants or sextants, or a symmetrical combination of these.

Types of participants

We considered trials with participants of any historic period and either gender, who reported PEB, regardless of the type of teeth (anterior or posterior, mandibular or maxillary).

Types of interventions

We considered any surgical or not‐surgical technique or material used for the handling of PEB. We had planned to make the post-obit comparisons.

Direct comparisons of dissimilar interventions
Intervention versus placebo or no treatment

Types of effect measures

Main outcomes

Haemorrhage ‐ measured past:

amount of blood loss;
complete cessation of haemorrhage, equally assessed clinically by the investigator;
time required for the command of bleeding.

Secondary outcomes

Patient‐reported outcomes related to hurting or discomfort during the procedure;
Treatment‐associated boilerplate cost;
Adverse effects.

Search methods for identification of studies

Electronic searches

Cochrane Oral Health'southward Information Specialist conducted systematic searches in the following databases for randomised controlled trials and controlled clinical trials without language or publication status restrictions:

Cochrane Oral Health'southward Trials Register (searched 24 January 2018) (Appendix 1);
Cochrane Central Register of Controlled Trials (Fundamental; 2017, Issue 12) in the Cochrane Library (searched 24 January 2018) (Appendix 2);
MEDLINE Ovid (1946 to 24 January 2018) (Appendix 3);
Embase Ovid (one May 2015 to 24 January 2018) (Appendix 4);
CINAHL EBSCO (Cumulative Index to Nursing and Allied Health Literature; 1937 to 24 Jan 2018) (Appendix 5).

Subject strategies were modelled on the search strategy designed for MEDLINE Ovid. Where appropriate, they were combined with subject strategy adaptations of the highly sensitive search strategy designed past Cochrane for identifying randomised controlled trials and controlled clinical trials as described in the Cochrane Handbook for Systematic Reviews of Interventions Affiliate 6 (Lefebvre 2011).

Due to the Cochrane Centralised Search Project to identify all clinical trials in the database and add them to Key, only nearly recent months of the Embase database were searched at the review's inception, and this search was updated for this version of the review. See the searching page on the Cochrane Oral Wellness website for more information. No other restrictions were placed on the date of publication when searching the electronic databases.

Searching other resources

The following trial registries were searched for ongoing studies:

US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov (clinicaltrials.gov; searched 24 Jan 2018) (Appendix 6);
Globe Wellness System International Clinical Trials Registry Platform (apps.who.int/trialsearch; searched 24 January 2018) (Appendix vii).

We searched the reference lists of relevant systematic reviews for further studies.

We did non perform a separate search for adverse furnishings of interventions.

Information collection and assay

Selection of studies

Three pairs of review authors (Ashok 50 (AL) and Prashanti Eachempati (PE), Himanshi Aggarwal (HA) and Kiran Kumar (KK), and Muthu MS (MMS) and Haszelini Hassan (HH)), independently and in duplicate, screened the titles and abstracts from the electronic searches to identify potentially eligible studies. The search was designed to be sensitive and include controlled clinical trials; these were filtered out early in the selection procedure if they were not randomised. Nosotros obtained full‐text copies of all eligible and potentially eligible studies, which were independently evaluated by two authors (Sumanth Kumbargere Nagraj (SKN) and PE) . We resolved disagreements past discussion. When resolution was not possible, we consulted an arbiter (Adinegara Lutfi Abas). We assessed articles in languages other than English after the abstracts had been translated (Tabular array 2). Nosotros did non discover any trials that fulfilled the inclusion criteria.

Data extraction and management

We had planned that 2 review authors (SKN, PE) would independently extract the data; and would non have been blinded to the authors. We would accept resolved whatever disagreements by discussion between the two review authors, if necessary, consulting a third review writer (PE) in order to reach consensus. We had planned to excerpt data using a customised information extraction grade. All the items in the data extraction form were designed following guidance from the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). We would have entered study details into the 'Characteristics of included studies' table in Review Manager (RevMan) software (RevMan 2014), recording the following details for each included trial:

publication details such as year of publication, language;
demographic details of the written report;
inclusion and exclusion criteria;
blazon of trial, sample size, method of randomisation, allocation darkening, blinding, method of assessing the outcomes and drop‐outs, if any;
type of intervention;
details of the outcomes reported;
duration of follow‐up;
results of the intervention;
funding details.

We had planned to write, electronic mail or telephone the contact author of included studies when description of details or additional information were required.

Assessment of run a risk of bias in included studies

Two review authors (SKN and PE) had planned to independently assess the gamble of bias in the included trials in seven domains:

random sequence generation (selection bias);
resource allotment darkening (selection bias);
blinding of participants and personnel (functioning bias);
blinding of consequence assessment (detection bias);
incomplete consequence data (attrition bias);
selective upshot reporting (reporting bias);
other biases.

For each of these components, we had planned to assign a judgment regarding the chance of bias as either high, low, or unclear based on guidance in Higgins 2011. Nosotros had planned to contact the trial authors if details were missing or unclear, and resolve disagreements through consensus. We had planned to record our judgements and justifications in 'Gamble of bias' tables for each included study and generate a 'Risk of bias' summary graph and figure. We would accept used these judgements to course the overall quality of prove for each comparison and outcome in the 'Summary of findings' tables.

Nosotros had planned to summarise the risk of bias according to Higgins 2011; meet Table 3.

two

Summarising the risk of bias for a body of bear witness

Risk of bias	Interpretation	In upshot	In included studies
Low chance of bias	Plausible bias unlikely to seriously alter the results	Low adventure of bias for all cardinal domains	Most data is from studies at low risk of bias
Unclear chance of bias	Plausible bias that raises some doubt almost the results	Unclear risk of bias for one or more key domains	About information is from studies at low or unclear take chances of bias
High chance of bias	Plausible bias that seriously weakens confidence in the results	High take chances of bias for one or more key domains	The proportion of data from studies at high chance of bias is sufficient to affect the estimation of results

Measures of treatment outcome

We had expected our chief consequence to be expressed in dichotomous data. We would accept expressed the upshot estimate as a adventure ratio (RR) with 95% conviction intervals (CI). We had expected our secondary outcomes to exist presented every bit dichotomous data, continuous data, or ordinal scales. Nosotros had planned to use means and standard deviations to calculate mean differences and 95% CI for continuous information measured with the same scales and standardised mean differences if studies used different scales to mensurate the same outcome.

If information were expressed in ordinal scales, nosotros had planned to explore the possibility of converting them to dichotomous outcomes. If outcomes were reported at baseline, trial endpoints, or follow‐up, we had planned to extract the hateful change and standard deviation from baseline for each treatment group. We had intended to pool either end scores or change scores, but preferred end scores when available; nosotros would have combined finish and change scores where necessary.

We had planned to analyse data expressed as counts (number of haemorrhage incidents) in the same style every bit continuous data.

Unit of analysis bug

We expected two types of non‐standard study designs in this review:

multiple treatment groups;
split‐mouth design

We were expecting data related to repeated observation on participants for our secondary outcome of fourth dimension required for the control of bleeding. In this case, we had planned to follow the method described in department 9.3.4 of the Cochrane Handbook (Higgins 2011).

In trials where adverse effects were described every bit counts, we wanted to follow the method described in section 9.2.5 of the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). In the case of dropouts, nosotros had planned to employ what the paper reports and deal with information technology in the 'Risk of bias' cess. We were not expecting to find any cluster‐randomised trials for this condition.

Dealing with missing data

We had planned to contact study authors to obtain missing data. We would have used the methods outlined in department 16.i.2 of the Cochrane Handbook for Systematic Reviews of Interventions to calculate missing standard deviations. If it had not been possible to calculate the SDs, we would take described the outcomes qualitatively (Higgins 2011).

Cess of heterogeneity

If meta‐analyses were performed, we would have assessed heterogeneity using a Chi² exam, where a P value < 0.ane indicated statistically significant heterogeneity. We would accept quantified heterogeneity using the I² statistic as follows:

0% to 40% implies slight heterogeneity;
30% to 60% moderate heterogeneity;
50% to ninety% substantial heterogeneity;
75% to 100% considerable heterogeneity.

If there was considerable heterogeneity (I² > 75%), which could not be explained past the subgroup analyses, we planned not to conduct meta‐analysis. We had planned to interpret I² values between 0% to forty% every bit possibly insignificant, xxx% to 60% as perhaps pregnant, 50% to 90% equally possibly substantial, and 75% to 100% as possibly very substantial ('considerable'); depending on whether the inconsistency in results was due to differences in the direction of upshot estimates between trials rather than due to differences in the magnitude of effect estimates favouring an intervention (Deeks 2011).

Assessment of reporting biases

If there were more than than ten studies included in a meta‐assay, we had planned to assess the possible presence of reporting bias by testing for asymmetry in a funnel plot. If present, we would accept carried out statistical analyses using the methods described by Egger 1997.

Data synthesis

We had planned to analyse the data using RevMan software (RevMan 2014). If the data available from the studies had similar comparisons and outcomes, we would have undertaken a meta‐analysis. Our general approach would take been to apply a random‐effects model. With this approach, the CIs for the average intervention issue are wider than those obtained using a fixed‐outcome approach, leading to a more bourgeois interpretation. Nosotros wanted to use all stop scores or all change scores when available, just would accept combined stop and change scores where necessary, using the criteria in section nine.four.v.ii of the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). We had planned to report the results from studies non included in a meta‐analysis in additional tables.

Subgroup analysis and investigation of heterogeneity

If there was significant heterogeneity, we had planned to explore the reasons by performing the following subgroup analyses based on different groups of patients. The subgroups were to be divided based on:

blazon of PEB (chief, reactionary, or secondary);
type of extraction (surgical or forceps);
type of underlying bleeding or clotting disorder (deficiency of factors, qualitative disorders, vessel disorders);
drug history (anticoagulant, antiplatelet, or combination);
type of teeth (deciduous or permanent, mobile or firm, maxillary or mandibular, inductive or posterior).

Sensitivity assay

If there were sufficient included studies, we would have undertaken sensitivity analysis based on take a chance of bias, including only studies at low adventure of bias.

Summarising findings and assessing the quality of the bear witness

We had planned to apply the Form arroyo to translate findings (Schunemann 2008). Nosotros had planned to use Form Profiler software (GRADEpro GDT 2014), and import data from RevMan 2014 to create 'Summary of findings' tables for each comparison included in the review. These tables were to provide information concerning the overall quality of the evidence from the trials, the magnitude of effect of the interventions examined, and the sum of available data on the primary and secondary outcomes. The Class approach considers 'quality' to be a judgment of the extent to which we tin can be confident that the estimates of result are right (Schunemann 2008). A trunk of evidence from randomised controlled studies is initially graded as high and downgraded by one or two levels on each of five domains, after full consideration of: whatsoever limitations in the design of the studies, the directness (or applicability) of the prove, the consistency of results, precision of the results, and the possibility of publication bias. A quality level of 'high' reflects conviction that the true effect lies shut to that of the estimate of the effect for an consequence. A sentence of 'moderate' quality indicates that the true effect is likely to be shut to the guess of the result, but acknowledges the possibility that it could be essentially different. 'Depression' and 'very low' quality show limit our conviction in the effect estimate (Balshem 2011).

Results

Description of studies

We found no published or ongoing randomised controlled trials that evaluated interventions for treating post‐extraction bleeding.

Results of the search

Our search strategy identified 1916 titles and abstracts of studies up to 24 January 2018. These were independently assessed for relevance by three pairs of review authors (AL and PE; HA and KK; MMS and HH). We checked the reference lists of the excluded studies and added some other 24 references. After removal of duplicates, we had a total of 1187 records. We rejected 1147 based on the abstracts. Nosotros obtained full texts for other xl trials. Twenty‐8 of these were not RCTs (studies not in English that we translated are listed in Appendix 8). We excluded the other 12 trials for reasons described beneath. None of the trials met the inclusion criteria for our review (Figure ii).

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Included studies

We did not observe whatsoever studies suitable for inclusion.

Adventure of bias in included studies

No trials were included.

Effects of interventions

See: Table ane

Summary of findings for the main comparison

Summary of findings for interventions to treat post‐extraction bleeding

Interventions for treating postal service‐extraction bleeding
Patient or population: people with postal service‐extraction haemorrhage Settings: hospital or dental practice
Outcomes	*Illustrative comparative risks (95% CI)**		Relative outcome (95% CI)	No of Participants (studies)	Quality of the evidence (Course)	Comments
	Causeless risk	Corresponding risk
Bleeding, every bit measured by: corporeality of blood loss; consummate cessation of haemorrhage, every bit assessed clinically by the investigator; fourth dimension required for the control of bleeding.	No information are available as no RCTs have been conducted on interventions to treat post‐extraction bleeding
Patient‐reported outcomes related to hurting or discomfort during the procedure
Treatment‐associated average cost
Adverse events
The basis for the assumed chance* (eastward.g. the median control group take a chance beyond studies) is provided in footnotes. The corresponding chance (and its 95% confidence interval) is based on the assumed risk in the comparing group and the relative result of the intervention (and its 95% CI). CI: confidence interval
GRADE Working Group grades of evidence Loftier quality: Further research is very unlikely to change our confidence in the judge of outcome. Moderate quality: Further research is probable to have an of import impact on our confidence in the estimate of effect and may change the judge. Low quality: Further inquiry is very likely to accept an of import bear on on our conviction in the estimate of effect and is likely to change the estimate. Very depression quality: We are very uncertain most the gauge.

No studies fulfilled our inclusion criteria.

Discussion

Post‐extraction haemorrhage (PEB) is one of the treatment complications of dental extraction that might make a patient panic and seek firsthand dental consultation. With the increasing number of patients on anticoagulant therapy with aspirin, warfarin, and clopidogrel, the chance of encountering PEB is increasing. Normally, these people are enlightened of their medical condition and study their medical history. It is normal to use precautionary measures to prevent PEB in such patients. Yet, this may not be the situation in depression‐ and middle‐income countries, where the majority of patients may not requite a proper medical and drug history, and medical records may non exist accessible. Hence, information technology is important to know how to control PEB in cases where no preventive measures were used.

Mail service‐extraction bleeding can too occur due to local or systemic problems that are not expected in routine dental extractions. Nosotros do non take whatever evidence‐based guidelines to manage such cases. The present review aimed to appraise the effects of various interventions for the treatment of different types of PEB.

We did not find whatsoever suitable trials to include in our review. This is because near of the trials advocated preventive measures prior to and immediately later on extraction, and reported either the incidence of PEB or tested preventive measures. Most of these trials reported the management of PEB based on clinician experience. Several trials tested whether anticoagulants, antiplatelets, or antifibrinolytics should be stopped before dental extraction, and reported varying incidence rates of PEB in control and intervention groups.

The bulk of the preventive trials randomised extraction cases into intervention groups. An ideal trial for this review would randomise PEB (master or reactionary or secondary) cases instead.

This topic seems to be an unexplored area of primary enquiry. We plant i observational trial in a German clinical trial register in which postoperative bleeding incidents afterwards dental treatment in patients with and without anticoagulant therapy were studied (DRKS00009286). We found no non‐Cochrane systematic reviews on this topic. We identified ii narrative reviews based on the authors' opinions (Leonard 1995; McCormick 2014a). We constitute two websites that have published guidelines to manage PEB (Emed handbook past Higginson 2007; University of Cambridge).

Nosotros observed the term 'mail service‐extraction bleeding' being used in unlike ways. Joshi 2014 used PEB terminology to describe the normal haemorrhage that happens subsequently dental extraction in their study. Al‐Bahlani 2001 describes any type of haemorrhage after dental extraction as postoperative haemorrhage. This can create defoliation and there is a need to standardise PEB terminology and its definition.

Authors' conclusions

Implications for do

We identified no published or ongoing randomised controlled clinical trials on interventions to treat post‐extraction bleeding, and then information technology is not possible to present evidence to clinicians or patients. In the absenteeism of whatsoever evidence from randomised controlled trials, clinicians should base of operations their decisions on clinical experience, in conjunction with testify from preventive trials.

Implications for research

There is a need for robust clinical trials to evaluate the effects of interventions for the treatment of PEB. Future randomised controlled trials should focus on interventions to control bleeding in patients subsequently the extraction, and in whom no preventive interventions have been advocated. This volition help us understand the all-time intervention strategy to be used if an emergency situation arises mail‐extraction, to control main, secondary or reactionary bleeding. Considering the varying incidence of PEB (0% to 26%), multicentric trials to accomplish appropriate sample size (power of the study) should exist conducted. Any future trials should exist well designed and reported according to the CONSORT argument (http://www.consort‐argument.org/).

What's new

Appointment	Issue	Description
14 May 2018	Review declared as stable	In that location are no completed or ongoing randomised controlled trials on this topic.

History

Protocol first published: Issue 10, 2015
Review beginning published: Issue vi, 2016

Date	Event	Description
21 February 2018	New citation required but conclusions accept non inverse	We excluded an additional three trials.
24 January 2018	New search has been performed	We updated our search to 20 February 2018. We made small changes to update the Background.

Notes

This review will no longer be updated as at that place are no completed or ongoing randomised controlled trials evaluating treatments for post‐extraction haemorrhage.

Acknowledgements

The authors would like to thank Pradeep Kumar for screening the titles and abstracts for the previous version of this review.

The authors thank Ms. Anne Littlewood, Data Specialist, Ms. Janet Lear, Ambassador, Ms. Laura CI MacDonald, Managing Editor, and Ms. Helen Wakeford, Deputy Managing Editor, all of Cochrane Oral Wellness. We give thanks Philip Riley and Ruth Floate for their comments. We also thank Ms. Shazana Binti Mohd Selva, Chief Librarian, Dr. Venkatachalapathy Suram, Professor, Professor Dr.Adinegara Lutfi Abas, Dean, Faculty of Medicine, Professor Dr. Abdul Rashid Haji Ismail, Dean, Faculty of Dentistry, Melaka Manipal Medical College, Manipal Academy of Higher Education, Melaka, Malaysia, and Professor Dr. Ravi Kant, Vice Chancellor, Male monarch George'due south Medical Academy, Lucknow, Republic of india for all the suggestions and help during the review preparation. We besides give thanks Dr. Naresh Yedthare Shetty, Senior Lecturer, International Medical University, Kuala Lumpur for his valuable suggestions.

We acknowledge the aid of foreign linguistic communication translators Joanna Zajac, Malgorzata Bala, Paul Tramini, Lilia Ziganshina, Karin Rau, Anette Blümle, Anna Misyail Abdul Rashid, Loh Zheng Tao, Giovanni Lodi, Andrea Pokorna, Maddalena Manfredi, Ubai Alsharif, Dr Liyuan Ma, Professor Chengge Hua, and Professor Zongdao Shi.

Appendices

Appendix 1. Cochrane Oral Health'southward Trials Register search strategy

((molar or teeth or molar* or bicuspid* or cuspid* or incisor*):ti,ab) AND (INREGISTER)
((extract* or remov* or surgery):ti,ab) AND (INREGISTER)
(#1 and #2) AND (INREGISTER)
((bleed* or "blood loss" or hemorrhag* or haemorrhag* or hemorrag* or haemorrag*):ti,ab) AND (INREGISTER)
(#3 and #4) AND (INREGISTER)

Appendix ii. The Cochrane Cardinal Register of Controlled Trials (CENTRAL) search strategy

#1 [mh ^"Tooth extraction"]
#two [mh Molar]
#3 (molar or teeth or molar* or bicuspid* or cuspid* or incisor*)
#4 [mh ^"Tooth, impacted"]
#v {or #two‐#four}
#half dozen (excerpt* or remov* or surgery)
#7 #5 and #6
#8 #1 or #7
#ix [mh ^"Blood loss, surgical"]
#10 [mh ^"Postoperative hemorrhage"]
#xi [mh ^"Hemorrhagic disorders"]
#12 [mh ^"Oral hemorrhage"]
#13 (bleed* or "blood loss" or hemorrhag* or haemorrhag* or hemorrag* haemorrag*)
#14 {or #ix‐#13}
#15 #8 and #14

Appendix 3. MEDLINE Ovid search strategy

ane. Tooth extraction/
2. exp Tooth/
iii. (molar or teeth or molar$ or bicuspid$ or cuspid$ or incisor$).ti,ab.
4. Tooth, impacted/
five. or/2‐four
six. (extract$ or remov$ or surgery).ti,ab.
7. 5 and half-dozen
viii. one or 7
9. Blood loss, surgical/
10. Postoperative hemorrhage/
11. Hemorrhagic disorders/
12. Oral hemorrhage/
thirteen. (bleed$ or "blood loss" or hemorrhag$ or haemorrhag$ or hemorrag$ or haemorrag$).ti,ab.
14. or/9‐13
15. 8 and xiv

This subject search was linked to the Cochrane Highly Sensitive Search Strategy (CHSSS) for identifying randomised trials in MEDLINE: sensitivity‐maximising version (2008 revision) as referenced in Chapter 6.4.xi.one and detailed in box 6.four.c of The Cochrane Handbook for Systematic Reviews of Interventions, Version 5.1.0 [updated March 2011] (Lefebvre 2011).

1. randomized controlled trial.pt.
2. controlled clinical trial.pt.
3. randomized.ab.
4. placebo.ab.
5. drug therapy.fs.
half-dozen. randomly.ab.
7. trial.ab.
8. groups.ab.
9. or/1‐eight
ten. exp animals/ non humans.sh.
11. nine not 10

Appendix 4. Embase Ovid search strategy

ane. Tooth extraction/
2. exp Tooth/
3. (tooth or teeth or molar$ or bicuspid$ or cuspid$ or incisor$).ti,ab.
4. 2 or 3
5. (extract$ or remov$ or surgery).ti,ab.
6. 4 and five
7. 1 or 6
8. Bleeding/
nine. Bleeding disorder/
10. Oral bleeding/
11. (bleed$ or "blood loss" or hemorrhag$ or haemorrhag$ or hemorrag$ or haemorrag$).ti,ab.
12. or/8‐11
13. 7 and 12

This subject search was linked to an adapted version of the Cochrane Centralised Search Projection filter for identifying RCTs in Embase Ovid (come across http://world wide web.cochranelibrary.com/help/central‐creation‐details.html for information):

ane. Randomized controlled trial/
two. Controlled clinical study/
3. Random$.ti,ab.
iv. randomization/
5. intermethod comparison/
6. placebo.ti,ab.
seven. (compare or compared or comparison).ti.
viii. ((evaluated or evaluate or evaluating or assessed or assess) and (compare or compared or comparison or comparing)).ab.
9. (open up adj label).ti,ab.
x. ((double or single or doubly or singly) adj (blind or blinded or blindly)).ti,ab.
eleven. double blind process/
12. parallel group$one.ti,ab.
thirteen. (crossover or cross over).ti,ab.
14. ((assign$ or match or matched or allotment) adj5 (alternate or group$ane or intervention$ane or patient$i or subject$1 or participant$1)).ti,ab.
15. (assigned or allocated).ti,ab.
16. (controlled adj7 (study or design or trial)).ti,ab.
17. (volunteer or volunteers).ti,ab.
18. trial.ti.
19. or/i‐xviii
twenty. (exp fauna/ or beast.hw. or nonhuman/) not (exp human/ or homo cell/ or (human being or humans).ti.)
21. nineteen not 20

Appendix v. CINAHL EBSCO search strategy

S13 S8 and S12
S12 S9 or S10 or S11
S11 (bleed* or "claret loss" or hemorrhag* or haemorrhag* or hemorrag* haemorrag*)
S10 (MH "Postoperative Hemorrhage")
S9 (MH "Blood Loss, Surgical")
S8 S1 or S7
S7 S5 and S6
S6 (extract* or remov* or surgery)
S5 S2 or S3 or S4
S4 (MH "Tooth, Impacted")
S3 (molar or teeth or molar* or bicuspid* or cuspid* or incisor*)
S2 (MH "Tooth+")
S1 (MH "Molar Extraction")

This subject area search was linked to Cochrane Oral Health's filter for CINAHL EBSCO:

S1 MH Random Assignment or MH Single‐blind Studies or MH Double‐blind Studies or MH Triple‐bullheaded Studies or MH Crossover blueprint or MH Factorial Design
S2 TI ("multicentre study" or "multicenter report" or "multi‐centre study" or "multi‐center written report") or AB ("multicentre study" or "multicenter report" or "multi‐centre written report" or "multi‐center study") or SU ("multicentre study" or "multicenter study" or "multi‐centre report" or "multi‐center written report")
S3 TI random* or AB random*
S4 AB "latin square" or TI "latin foursquare"
S5 TI (crossover or cross‐over) or AB (crossover or cross‐over) or SU (crossover or cantankerous‐over)
S6 MH Placebos
S7 AB (singl* or doubl* or trebl* or tripl*) or TI (singl* or doubl* or trebl* or tripl*)
S8 TI bullheaded* or AB mask* or AB bullheaded* or TI mask*
S9 S7 and S8
S10 TI Placebo* or AB Placebo* or SU Placebo*
S11 MH Clinical Trials
S12 TI (Clinical AND Trial) or AB (Clinical AND Trial) or SU (Clinical AND Trial)
S13 S1 or S2 or S3 or S4 or S5 or S6 or S9 or S10 or S11 or S12

Appendix six. US National Institutes of Health Trials Registry (ClinicalTrials.gov) search strategy

"oral surgery" and bleed

"oral surgery" and hemorrhage

tooth and extraction and bleed

tooth and extraction and hemorrhage

Appendix seven. The WHO International Clinical Trials Registry Platform search strategy

Oral surgery and drain

Oral surgery and hemorrhage

Oral surgery and haemorrhage

Molar extraction and bleed

Molar extraction and hemorrhage

Tooth extraction and haemorrhage

Appendix 8. Studies we translated and rejected as ineligible for inclusion

Trial identification	Title	Linguistic communication	Translator/s	Reasons for rejection
Trentalancia 1967	The use of 5‐oxytryptamine in post‐extraction haemorrhages	Italian	Giovanni Lodi	i. The study is not randomised. Randomisation is never mentioned. The writer stated that "the patients have been divided as follows" (page 1386). ii. Patients were at risk of haemorrhage, and non with post‐extraction bleeding.
Pavek 1976	Evaluation of the haemostatic effect of Dicynon in dentoalveolar surgery	Czech	Andrea Pokorna	The written report does not fulfil criteria equally it describes awarding of Dicynone in four groups of patients – no randomisation, no detailed clarification of the patient groups.
Szpirglas 1979	Stomatological haemorrhages; haemostasis with GRF (gelatin‐resorcin‐formol)	Italian	Maddalena Manfredi	This study is a description of a topical haemostasis technique without any study about patients.
Marini 1966	Therapy of post‐extraction haemorrhages in haemophiliac patients with epsilon‐aminocaproic acid (EACA).	Italian	Maddalena Manfredi	This is a case serial.
Torteli 1965	Use of "reptilase" in postoperative haemorrhage of the dental appliance	High german	Ubai Alsharif	This is a case series of 14 patients who were treated with Raptilase, and does not fulfil the inclusion criteria.
Zhou 1985	Prevention and treatment of haemorrhage afterward extraction of teeth by using the pulvis of cibotium barometz‐alum burn	Chinese	Dr Liyuan Ma, Professors Chengge Hua, Zongdao Shi and Mr.Loh Zheng Tao	The trial is a RCT with 2 artillery; nevertheless, the randomisation method is not reported. This is a preventive study for reducing post‐extraction complications including PEB, instead of managing post‐extraction bleeding.
Antoszewski 1972	Cepevit‐Thousand training in controlling haemorrhages and bleeding post-obit tooth extraction	Shine	Joanna Zajac and Malgorzata Bala	Not a randomised controlled trial. They used Cepevit‐Grand: ‐ after extraction for 22 patients (for 17, bleeding was stopped within eight minutes; chirurgical treatment was provided for the others). ‐ two days earlier extraction in 18 patients with low coagulation time (for four patients in this group, additional chirurgical treatment was needed). The only comparison is twenty other people with haemorrhage later molar extraction, where the author used other techniques (other than chirurgical handling); information technology only worked for 8 patients, and then the other 12 were given Cepevit‐Chiliad.
Fetkowska‐Mielnik 1969	Clinical evaluation of the results of treatment of mail‐extraction bleeding with new drugs Eastward.A.C.A., styptanon	Polish	Joanna Zajac and Malgorzata Bala	Not a randomised controlled trial. Study was based on observation of 69 patients, all with claret coagulation problems: some after extraction with bleeding, some before extraction. For all blood analyses were washed and co-ordinate to results: ‐ for some: epsilon aminocaproic acid (EACA) was used ‐ for others: Styptanon was used ‐ for others: EACA and Styptanon together
Khomiachenko 1978	Use of aminocaproic acid for stopping the bleeding after tooth extraction	Russian	Lilia Ziganshina and Anna Misyail Abdul Rashid	This is an abstract describing 100% success of 5% aminocapronic acid in 135 patients. This was not a trial; there was no comparing.
Neuner 1968	Therapy of haemorrhage following extractions	German	Karin Rau and Anette Bluemle	This is not a randomised command trial. In this publication, the interventions for postal service‐extraction bleeding are explained in detail, just not within the scope of a clinical study.
Saltykova 1974	The use of new haemostatic drug in dental practice	Russian	Lilia Ziganshina and Anna Misyail Abdul Rashid	This is a single case report.
Martineau 1989	Hemorrhage in the dental part. Study of local haemostatic handling	French	Paul Tramini	This paper is just a recommendation for practitioners and students in instance of PEB problems. No data are available.
Rokicka‐Milewska 1966	Application of epsilon‐aminocaproic acid for oral mucosal bleeding in haemophiliacs	Smooth	Joanna Zajac and Malgorzata Bala	This article is not a RCT. All participants (13 children with haemophilia: nine type A and iv type B) received epsilon‐aminocaproic (20% solution) acid 24 hours before molar extraction. Intolerance developed in some children, and then the dose was changed (from 0.ane one thousand/kg of body weight to 0.05g/kg), or the drug was administered intravenously.

Notes

Stable (no update expected for reasons given in 'What's new')

Characteristics of studies

Characteristics of excluded studies [ordered by study ID]

Differences between protocol and review

We changed the title from 'managing' to 'treating'. We made this change throughout every bit 'managing' could be interpreted as including prevention, which was not our intention.

Effigy 1 in the protocol has been modified to Tabular array 1 in the review ('Types of haemorrhage afterwards dental extractions').

Principal and secondary outcomes are re‐worded without changing the pregnant.

We had mentioned nether selection of studies that ii pairs of review authors would independently screen the titles and abstracts to identify potentially eligible studies. However, 3 pairs of review authors screened the titles and abstracts.

Equally we did not have whatever included trials, the contribution of authors differed from what we had planned.

Contributions of authors

Sumanth Kumbargere Nagraj: drafting the protocol, evaluation of full text manufactures for inclusion or exclusion, drafting the concluding review, and updating the review.
Eachempati Prashanti: drafting the protocol, screening titles and abstracts, evaluation of total text articles for inclusion or exclusion and updating the review.
Himanshi Aggarwal: drafting the protocol, screening titles and abstracts, and drafting the terminal review.
Ashok Lingappa: content expert, screening titles and abstracts.
Murugan Southward Muthu: content skillful, screening titles and abstracts, and drafting the concluding review.
Salian Kiran Kumar Krishanappa: undertaking searches, screening titles and abstracts.
Haszelini Hassan: content practiced, screening titles and abstracts, and drafting the final review.

Sources of support

Internal sources

Faculty of Dentistry, Melaka Manipal Medical College, Manipal Academy, Melaka Campus, Malaysia.

Library support and providing preparation in Cochrane Systematic Reviews

External sources

National Plant for Health Research (NIHR), UK.

This project was supported by the NIHR, via Cochrane Infrastructure funding to Cochrane Oral Health. The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the Systematic Reviews Program, NIHR, NHS or the Section of Wellness.
Cochrane Oral Wellness Global Brotherhood, Other.

The product of Cochrane Oral Wellness reviews has been supported financially by our Global Alliance since 2011 (oralhealth.cochrane.org/partnerships‐alliances). Contributors over the past year have been the American Association of Public Health Dentistry, USA; As‐Akademie, Germany; the British Association for the Study of Community Dentistry, United kingdom of great britain and northern ireland; the British Society of Paediatric Dentistry, Britain; the Canadian Dental Hygienists Association, Canada; the Centre for Dental Education and Inquiry at All Republic of india Establish of Medical Sciences, India; the National Center for Dental Hygiene Inquiry & Practice, U.s.a.; New York Academy College of Dentistry, United states; and NHS Teaching for Scotland, U.k.; Swiss Society of Endodontology, Switzerland.

Declarations of interest

Sumanth Kumbargere Nagraj: no interests to declare
Eachempati Prashanti: no interests to declare
Himanshi Aggarwal: no interests to declare
Ashok Lingappa: no interests to declare
Murugan Southward Muthu: no interests to declare
Salian Kiran Kumar Krishanappa: no interests to declare
Haszelini Hassan: no interests to declare

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