Extraction Started Bleeding Again a Day Later

• Periodical List
• Cochrane Database Syst Rev
• PMC6494262

Cochrane Database Syst Rev. 2018 Mar; 2018(3): CD011930.

Interventions for treating postal service‐extraction bleeding

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

Faculty of Dentistry, Melaka‐Manipal Medical College, Manipal University of College Pedagogy (MAHE), Manipal, Department of Oral Medicine and Oral Radiology, Jalan Batu Hampar, Bukit Baru, MelakaMalaysia, 75150

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

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

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

Faculty of Dental Sciences, Sri Ramachandra Academy, Paediatric Dentistry, 2C Akme Park, Pedo Planet, Paediatric Dental Centre, OPP Due south&S POWER 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

Groundwork

Post‐extraction bleeding (PEB) is a recognised, frequently encountered complication in dental practice, which is defined every bit bleeding that continues beyond 8 to 12 hours subsequently dental extraction. The incidence of mail service‐extraction bleeding varies from 0% to 26%. If post‐extraction bleeding is not managed, complications can range from soft tissue haematomas to severe blood loss. Local causes of bleeding include soft tissue and bone haemorrhage. Systemic causes include platelet problems, coagulation disorders or excessive fibrinolysis, and inherited or caused problems (medication induced). There is a broad array of techniques suggested for the treatment of postal service‐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 effects of interventions for treating dissimilar types of post‐extraction bleeding.

Search methods

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

Choice criteria

Nosotros considered randomised controlled trials (RCTs) that evaluated any intervention for treating PEB, with male person or female participants of any age, regardless of blazon of teeth (anterior or posterior, mandibular or maxillary). Trials could compare 1 blazon of intervention with another, with placebo, or with no treatment.

Data drove and analysis

Three pairs of review authors independently screened search records. Nosotros obtained full papers for potentially relevant trials. If information 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 not find whatever 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 effects of unlike interventions for the handling of post‐extraction bleeding. In view of the lack of reliable show on this topic, clinicians must apply their clinical experience to determine the near 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 suit to the CONSORT statement (www.consort‐statement.org/).

Manifestly linguistic communication summary

Interventions for managing bleeding after molar removal

Review question

We conducted this review to assess different interventions for treating bleeding after molar removal.

Groundwork

After tooth extraction, it is normal for the surface area to drain so jell, generally within a few minutes. It is aberrant if bleeding continues without clot germination, or lasts beyond 8 to 12 hours; this is known as mail service‐extraction bleeding (PEB). Such bleeding incidents tin cause distress for patients, who might need emergency dental consultations and interventions. The causes of PEB can be local, a systemic disease, or a medication. To command this haemorrhage, many local and systemic methods have been practised, based on the clinician'southward expertise. To inform clinicians about the best handling, show is needed from studies where people take been randomly allocated to one of at to the lowest degree 2 different groups, which receive different treatments, or no treatment (i.e. 'randomised controlled trials' or RCTs).

Study characteristics

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

Key results and quality of the bear witness

This review revealed that there is no RCT evidence for the effectiveness of any bachelor intervention for treating post‐extraction bleeding. Loftier quality RCTs are needed to help clinicians and patients make informed choices about treatment options.

Summary of findings

Background

Description of the status

Molar removal, or extraction, is one of the about common invasive oral surgical procedures carried out in routine dental practice (Van Galen 2014), and postal service‐extraction bleeding is a recognised, frequently encountered complication (McCormick 2014a). Immediately following the removal of a tooth, haemorrhage or oozing normally occurs. This bleeding can be easily controlled in most cases (Amer 2014), and almost completely stops within eight hours of extraction. However, sometimes it may continue, resulting in a life‐threatening situation (Funayama 1994). It is of import to distinguish betwixt active bleeding from the surgical site and oozing. The active bleeding complexity is unremarkably termed 'post‐extraction bleeding' (PEB) or 'post‐operative haemorrhage after extraction'. Amer 2014 has described PEB as "evidence of bleeding beyond the pressure pack". Lockhart 2003 has provided four criteria to define PEB, namely that it:

1. continues across 12 hours;

2. causes the patient to call or return to the dental practitioner, or go to the accident and emergency department;

3. results in the development of a large haematoma or ecchymosis within the oral soft tissues; or

4. requires a claret 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 0.4% (Chiapasco 1993). Jensen 1974 reviewed 103 cases of postoperative prolonged haemorrhage after oral surgery and reported that 75% of PEB occurred within viii hours of the surgery, and only four patients had coagulation deficiencies. He also reported that postoperative prolonged bleeding from the mandibular molars is more common (80%) than bleeding from the maxillary molars (20%) considering of the highly vascular floor of the oral cavity. Wells 2000 reported that the run a risk of prolonged haemorrhage was 0.2% to 1.iv% in cases of third tooth removal surgery. Iwabuchi 2014 reported ii.77% clinically‐significant PEB in patients receiving warfarin therapy, and 0.39% in not‐warfarin groups, regardless of the type of teeth (95% CI 0.65% to 4.10%). Kataoka 2016 reported that the incidence of PEB ranged from 0 to 26% in their cohort study. Yagyuu 2017 reported that the hazard of postal service‐extraction haemorrhage was like for patients on directly oral anticoagulants and Vitamin K antagonist extractions.

Post‐extraction haemorrhage has been attributed to diverse factors that tin can be broadly classified equally local and systemic (McDonnell 2013; Van Galen 2014). Post‐extraction bleeding tin be acquired locally, from soft tissue or os haemorrhage. Soft tissue bleeding tin exist due to traumatic extraction, leading to laceration of claret vessels (arterial, venous or capillary). Os or osseous haemorrhage can be from either the nutrient 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 mail service‐extraction instructions accept too been associated with PEB. Systemic factors include platelet bug, coagulation disorders or excessive fibrinolysis, and inherited or acquired problems (medication induced).

Mail service‐extraction bleeding tin exist categorised as principal prolonged bleeding, intermediate or reactionary prolonged bleeding, and secondary prolonged bleeding. Chief 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 bone. Patients with main prolonged bleeding present with their mouth actively filling with blood immediately after removing the haemostatic dressing. Reactionary bleeding occurs a few hours mail service‐extraction and is more than common in patients with systemic disorders or patients on anticoagulant therapy. Secondary bleeding (liver clots) unremarkably occurs 7 to 10 days after extraction, and is a complication rarely encountered in dental practice (Malik 2008; Table 2). Abdullah 2014 has classified PEB equally mild (oozing), moderate (haemorrhage persisting on the 2d twenty-four hours of extraction), and severe (any bleeding that needed hospitalisation).

1

Types of bleeding after dental extractions

Normal bleeding	Mail‐extraction haemorrhage
	Primary	Reactionary	Secondary
Normally persists for up to half an hour Oozing and claret tinged saliva for upwardly to 8 hours Controlled by pressure pack	Occurs during and immediately later on extraction Typically presents as claret filling up the oral cavity Unremarkably due to infection or trauma to blood vessels Frequently controlled by local techniques similar force per unit area packs, haemostatic agents, etc	Begins 2 to three hours post extraction, after the vasoconstrictor effect of local anaesthesia wears off Commonly due to underlying systemic conditions such as bleeding or clotting disorders Not controlled by local measures and may crave systemic interventions	Usually begins 7 to x days post extraction Mainly due to secondary infection Rare in dental extractions, compared to the other ii types of mail service‐extraction bleeding

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

Clarification of the intervention

The handling of bleeding complications following a dental extraction is an essential skill for the dental practitioner (McCormick 2014b). Clinical decision making on how to control PEB depends on multiple factors, including the surgical location and site of bleeding, wound size, extent of bleeding, accessibility of the bleeding site, and timing of haemorrhage (Howe 2013). Furthermore, the option of an intervention strategy to achieve 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 every bit cirrhosis, that can touch bleeding and coagulation (McCormick 2014b).

Interventions for treating PEB can be broadly categorised into local and systemic interventions. Local interventions can be farther subdivided into surgical interventions, not‐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, cover an array of pharmacotherapies, sealants, adhesives, absorbable agents, biologics, and combination products (Howe 2013). Mutual haemostatic agents used in oral surgery in extraction sites include the post-obit (Al‐Belasy 2003; Mingarro‐de‐León A 2014): local pressure level application with gauze, oxidised cellulose (Abdullah 2014), gel cream, thrombin, collagen fleeces (Baumann 2009), cyanoacrylate glue, acrylic or surgical splints (Anderson 2013), local antifibrinolytic solutions, such equally tranexamic acrid mouthwash (Carter 2003), fibrin glue or adhesive (Cocero 2015), resorbable gelatin sponge, collagen sponge, gauze soaked with tranexamic acrid (Perdigão 2012), chlorhexidine bio‐agglutinative 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.

• Diverse combinations of surgical and non‐surgical interventions have also been used, such as tranexamic acid mouthwash along with gelatin sponge and sutures, and fibrin glue with collagen fleece and sutures (Al‐Belasy 2003).

Systemic interventions

Systemic interventions are especially important in patients who have an associated systemic cause for haemorrhage. The role of local haemostatics is limited in these cases, because their utilise results in only temporary abeyance of bleeding (Auluck 2004). Systemic interventions include assistants 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 case of haemophilia, and plasma‐derived Von Willebrand factor (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 acrid (Morimoto 2004), oral or intravenous epsilon amino‐d‐caproic acid (Van Galen 2014). There are contradictory opinions on discontinuation of antithrombotic medications; for case, Aframian 2007 suggests the discontinuation of these medications, whereas Wahl 2016 suggests these medications for dental procedures should not be interrupted, as the prognosis of potential post‐extraction haemorrhage that could result from antithrombotic continuation is better than the prognosis of a potential stroke or heart attack that could follow antithrombotic pause.

How the intervention might piece of work

Haemostasis, or control of bleeding, in the oral crenel is dependent on the dynamic balance between fibrin germination and resolution and is influenced by the external environs, which contains both plasminogen and plasminogen activators (Carter 2003). It is a complex interaction between platelets, plasma proteins, and coagulation and fibrinolytic pathways. The clotting cascade 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 three main phases: initiation, distension, 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 distension phase (Glick 2013), and provide the initial haemostatic response (Traver 2006). Finally, fibrin formation and stabilisation of the platelet jell occur during the propagation stage (Glick 2013).

Unlike phases of coagulation

Dissimilar interventions to control PEB basically interfere with the clotting pour at different levels, resulting in abeyance of haemorrhage. The machinery of action of diverse interventions can be broadly summarised, based on the unlike phases.

• Initiation phase: pressure packs, suture, bone wax, cellulose, styptics, gel cream, tranexamic acid, aminocaproic acid, cryoprecipitate, desmopressin (DDAVP), factor VIII concentrate and prothrombin circuitous concentrate (PCC) act at different stages of this phase.

• Amplification phase: ethamsylate, haemostatic collagen and Actcell^® deed during this stage.

• Propagation phase: cryoprecipitate and recombinant factor (VIIa) act during this phase.

Local interventions work either mechanically or past augmenting the coagulation pour. Haemostatic agents human activity to stop haemorrhage past causing vasoconstriction or promoting platelet assemblage, whereas tissue adhesives or sealants demark to and close defects in tissue (Traver 2006). Systemic interventions work past inhibiting fibrinolysis or promoting coagulation (Van Galen 2014).

Why it is important to do this review

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

A wide array of techniques are suggested for the treatment of PEB and unlike guidelines take been published (Higginson 2007; University of Cambridge). Until our outset 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 care for PEB and provide evidence to guide clinical dental do. Considering the unlike complex interventions addressing various issue measures, it seems important to try to draw the components of interventions and to identify 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 also needed since interventions of questionable effectiveness and unclear consequences might be in employ.

Objectives

To assess the effects of interventions for treating different types of mail service‐extraction bleeding.

Methods

Criteria for considering studies for this review

Types of studies

We considered randomised controlled trials (RCTs) evaluating any intervention for treating post‐extraction haemorrhage (PEB). We excluded quasi‐RCTs, cross‐over trials and preventive trials. We had planned to include split‐mouth studies, provided there was no possibility of contamination. Split‐mouth design is one of the self‐controlled report designs that is unique to dentistry. The blueprint is characterised by subdividing the oral cavity of the subject field 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 treatment of PEB. We had planned to make the following comparisons.

1. Direct comparisons of different interventions

2. Intervention versus placebo or no treatment

Types of result measures

Primary outcomes

1. Bleeding ‐ measured by:

• amount of claret loss;

• complete cessation of bleeding, as assessed clinically by the investigator;

• fourth dimension required for the control of bleeding.

Secondary outcomes

1. Patient‐reported outcomes related to pain or discomfort during the procedure;

2. Treatment‐associated boilerplate cost;

3. Adverse furnishings.

Search methods for identification of studies

Electronic searches

Cochrane Oral Health's Information Specialist conducted systematic searches in the post-obit databases for randomised controlled trials and controlled clinical trials without linguistic communication or publication condition restrictions:

• Cochrane Oral Wellness's Trials Register (searched 24 Jan 2018) (Appendix 1);

• Cochrane Central Annals of Controlled Trials (Primal; 2017, Issue 12) in the Cochrane Library (searched 24 Jan 2018) (Appendix 2);

• MEDLINE Ovid (1946 to 24 January 2018) (Appendix 3);

• Embase Ovid (i May 2015 to 24 January 2018) (Appendix 4);

• CINAHL EBSCO (Cumulative Index to Nursing and Centrolineal Health Literature; 1937 to 24 January 2018) (Appendix 5).

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

Due to the Cochrane Centralised Search Project to identify all clinical trials in the database and add together them to Cardinal, only most contempo months of the Embase database were searched at the review's inception, and this search was updated for this version of the review. Run across the searching page on the Cochrane Oral Health website for more than information. No other restrictions were placed on the appointment of publication when searching the electronic databases.

Searching other resource

The following trial registries were searched for ongoing studies:

• US National Institutes of Wellness Ongoing Trials Annals ClinicalTrials.gov (clinicaltrials.gov; searched 24 Jan 2018) (Appendix 6);

• Globe Health Organization International Clinical Trials Registry Platform (apps.who.int/trialsearch; searched 24 Jan 2018) (Appendix 7).

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

Nosotros did non perform a split up search for adverse effects of interventions.

Information collection and analysis

Pick of studies

Iii pairs of review authors (Ashok L (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) . Nosotros resolved disagreements by discussion. When resolution was non possible, we consulted an arbiter (Adinegara Lutfi Abas). We assessed manufactures in languages other than English language afterwards the abstracts had been translated (Table 2). We did non find any trials that fulfilled the inclusion criteria.

Data extraction and management

We had planned that two review authors (SKN, PE) would independently excerpt the data; and would not accept been blinded to the authors. We would have resolved whatsoever disagreements by discussion between the two review authors, if necessary, consulting a third review author (PE) in order to attain consensus. Nosotros had planned to extract data using a customised information extraction form. 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 Director (RevMan) software (RevMan 2014), recording the following details for each included trial:

• publication details such every bit twelvemonth of publication, language;

• demographic details of the report;

• inclusion and exclusion criteria;

• type of trial, sample size, method of randomisation, allocation concealment, 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, email or telephone the contact author of included studies when clarification of details or additional data were required.

Assessment of risk of bias in included studies

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

• random sequence generation (option bias);

• allocation concealment (choice bias);

• blinding of participants and personnel (operation bias);

• blinding of outcome assessment (detection bias);

• incomplete outcome information (attrition bias);

• selective issue reporting (reporting bias);

• other biases.

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

We had planned to summarise the take chances of bias according to Higgins 2011; see Table 3.

2

Summarising the risk of bias for a body of evidence

Risk of bias	Interpretation	In upshot	In included studies
Low take chances of bias	Plausible bias unlikely to seriously modify the results	Low risk of bias for all key domains	Most data is from studies at low risk of bias
Unclear risk of bias	Plausible bias that raises some dubiety about the results	Unclear gamble of bias for one or more primal domains	Near information is from studies at low or unclear risk of bias
Loftier risk of bias	Plausible bias that seriously weakens conviction in the results	Loftier take chances of bias for one or more key domains	The proportion of data from studies at loftier risk of bias is sufficient to affect the interpretation of results

Measures of handling consequence

We had expected our primary outcome to be expressed in dichotomous information. We would have expressed the result estimate as a gamble ratio (RR) with 95% confidence intervals (CI). We had expected our secondary outcomes to be presented as dichotomous data, continuous data, or ordinal scales. We had planned to use means and standard deviations to calculate hateful differences and 95% CI for continuous data measured with the same scales and standardised hateful differences if studies used different scales to measure the same event.

If data 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‐upwardly, we had planned to extract the mean change and standard deviation from baseline for each treatment group. Nosotros had intended to pool either end scores or change scores, but preferred end scores when available; we would have combined cease and change scores where necessary.

Nosotros had planned to analyse data expressed as counts (number of bleeding incidents) in the same way as continuous data.

Unit of analysis issues

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

• multiple treatment groups;

• dissever‐mouth design

Nosotros were expecting data related to repeated ascertainment on participants for our secondary issue of time required for the control of haemorrhage. In this case, we had planned to follow the method described in section 9.3.four 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.ii.5 of the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). In the case of dropouts, we had planned to use what the paper reports and bargain with information technology in the 'Risk of bias' assessment. We were not expecting to find any cluster‐randomised trials for this condition.

Dealing with missing information

We had planned to contact written report authors to obtain missing data. Nosotros would accept used the methods outlined in section 16.1.2 of the Cochrane Handbook for Systematic Reviews of Interventions to calculate missing standard deviations. If it had not been possible to summate the SDs, we would take described the outcomes qualitatively (Higgins 2011).

Assessment of heterogeneity

If meta‐analyses were performed, we would have assessed heterogeneity using a Chi² test, where a P value < 0.1 indicated statistically significant heterogeneity. Nosotros would have quantified heterogeneity using the I² statistic as follows:

• 0% to twoscore% implies slight heterogeneity;

• 30% to lx% moderate heterogeneity;

• 50% to 90% substantial heterogeneity;

• 75% to 100% considerable heterogeneity.

If there was considerable heterogeneity (I² > 75%), which could non be explained by the subgroup analyses, we planned non to conduct meta‐analysis. We had planned to interpret I² values between 0% to 40% every bit possibly insignificant, 30% to threescore% equally possibly significant, 50% to 90% as perhaps 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 effect estimates between trials rather than due to differences in the magnitude of outcome estimates favouring an intervention (Deeks 2011).

Assessment of reporting biases

If there were more than 10 studies included in a meta‐analysis, we had planned to assess the possible presence of reporting bias by testing for asymmetry in a funnel plot. If nowadays, we would have 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 like comparisons and outcomes, we would have undertaken a meta‐analysis. Our general approach would have been to use a random‐effects model. With this arroyo, the CIs for the average intervention consequence are wider than those obtained using a fixed‐event approach, leading to a more than conservative interpretation. We wanted to use all end scores or all alter scores when available, only would have combined stop and modify scores where necessary, using the criteria in section 9.iv.5.2 of the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). We had planned to written report the results from studies non included in a meta‐assay in additional tables.

Subgroup analysis and investigation of heterogeneity

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

• type of PEB (main, reactionary, or secondary);

• type of extraction (surgical or forceps);

• type of underlying haemorrhage or clotting disorder (deficiency of factors, qualitative disorders, vessel disorders);

• drug history (anticoagulant, antiplatelet, or combination);

• blazon of teeth (deciduous or permanent, mobile or firm, maxillary or mandibular, inductive or posterior).

Sensitivity analysis

If at that place were sufficient included studies, we would have undertaken sensitivity assay based on run a risk of bias, including only studies at low take chances of bias.

Summarising findings and assessing the quality of the show

We had planned to use the Grade approach to translate findings (Schunemann 2008). We had planned to apply Class Profiler software (GRADEpro GDT 2014), and import information from RevMan 2014 to create 'Summary of findings' tables for each comparison included in the review. These tables were to provide information apropos 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 Form arroyo considers 'quality' to be a judgment of the extent to which nosotros can be confident that the estimates of effect are correct (Schunemann 2008). A trunk of bear witness 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: any limitations in the design of the studies, the directness (or applicability) of the evidence, the consistency of results, precision of the results, and the possibility of publication bias. A quality level of 'loftier' reflects confidence that the true effect lies shut to that of the estimate of the effect for an outcome. A sentence of 'moderate' quality indicates that the true effect is likely to be close to the gauge of the effect, but acknowledges the possibility that it could be substantially unlike. 'Low' and 'very low' quality testify limit our conviction in the issue guess (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 another 24 references. After removal of duplicates, nosotros had a full of 1187 records. We rejected 1147 based on the abstracts. Nosotros obtained full texts for other forty trials. 20‐8 of these were not RCTs (studies not in English language that we translated are listed in Appendix 8). We excluded the other 12 trials for reasons described below. None of the trials met the inclusion criteria for our review (Effigy 2).

Included studies

We did not find whatever studies suitable for inclusion.

Risk of bias in included studies

No trials were included.

Effects of interventions

See: Tabular array i

Summary of findings for the main comparison

Summary of findings for interventions to treat postal service‐extraction bleeding

Interventions for treating post‐extraction bleeding
Patient or population: people with mail service‐extraction bleeding Settings: hospital or dental exercise
Outcomes	Illustrative comparative risks* (95% CI)		Relative result (95% CI)	No of Participants (studies)	Quality of the evidence (Grade)	Comments
	Causeless risk	Corresponding take a chance
Bleeding, every bit measured by: amount of blood loss; complete cessation of haemorrhage, every bit assessed clinically by the investigator; time required for the control of haemorrhage.	No data are available as no RCTs have been conducted on interventions to treat postal service‐extraction bleeding
Patient‐reported outcomes related to pain or discomfort during the process
Treatment‐associated average cost
Adverse events
*The basis for the assumed run a risk (e.g. the median control group run a risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparing group and the relative effect of the intervention (and its 95% CI). CI: confidence interval
Course Working Group grades of prove High quality: Further inquiry is very unlikely to alter our conviction in the estimate of effect. Moderate quality: Further research is likely to accept an important affect on our confidence in the guess of effect and may modify the gauge. Low quality: Farther inquiry is very likely to accept an of import bear on on our confidence in the estimate of outcome and is likely to change the approximate. Very low quality: We are very uncertain about the gauge.

No studies fulfilled our inclusion criteria.

Word

Post‐extraction bleeding (PEB) is ane of the handling 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. Unremarkably, these people are aware of their medical condition and report their medical history. It is normal to utilise precautionary measures to prevent PEB in such patients. However, this may non exist the state of affairs in low‐ and middle‐income countries, where the bulk of patients may not requite a proper medical and drug history, and medical records may not be accessible. Hence, it is of import to know how to control PEB in cases where no preventive measures were used.

Post‐extraction bleeding can also occur due to local or systemic problems that are not expected in routine dental extractions. We do non have any bear witness‐based guidelines to manage such cases. The present review aimed to assess the effects of various interventions for the handling of different types of PEB.

We did non find any suitable trials to include in our review. This is because almost of the trials advocated preventive measures prior to and immediately afterwards extraction, and reported either the incidence of PEB or tested preventive measures. Most of these trials reported the direction of PEB based on clinician feel. 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 majority of the preventive trials randomised extraction cases into intervention groups. An ideal trial for this review would randomise PEB (primary or reactionary or secondary) cases instead.

This topic seems to be an unexplored area of principal inquiry. Nosotros found one observational trial in a German clinical trial register in which postoperative haemorrhage incidents after dental treatment in patients with and without anticoagulant therapy were studied (DRKS00009286). We found no not‐Cochrane systematic reviews on this topic. We identified two narrative reviews based on the authors' opinions (Leonard 1995; McCormick 2014a). We plant two websites that accept published guidelines to manage PEB (Emed handbook past Higginson 2007; University of Cambridge).

We observed the term 'post‐extraction bleeding' beingness used in different means. Joshi 2014 used PEB terminology to describe the normal bleeding that happens after dental extraction in their written report. Al‐Bahlani 2001 describes whatever blazon of bleeding after dental extraction as postoperative bleeding. This can create confusion and there is a need to standardise PEB terminology and its definition.

Authors' conclusions

Implications for practice

We identified no published or ongoing randomised controlled clinical trials on interventions to treat post‐extraction bleeding, so it is non possible to nowadays evidence to clinicians or patients. In the absence of whatever show from randomised controlled trials, clinicians should base of operations their decisions on clinical feel, in conjunction with evidence from preventive trials.

Implications for inquiry

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 after the extraction, and in whom no preventive interventions have been advocated. This will help us sympathize the all-time intervention strategy to be used if an emergency situation arises postal service‐extraction, to control main, secondary or reactionary bleeding. Because the varying incidence of PEB (0% to 26%), multicentric trials to achieve appropriate sample size (ability of the report) should be conducted. Any future trials should be well designed and reported according to the Consort statement (http://www.espoused‐statement.org/).

What'due south new

Date	Event	Clarification
14 May 2018	Review declared as stable	There are no completed or ongoing randomised controlled trials on this topic.

History

Protocol first published: Event 10, 2015
Review first published: Effect half dozen, 2016

Date	Event	Description
21 Feb 2018	New citation required just conclusions have not changed	We excluded an boosted 3 trials.
24 January 2018	New search has been performed	Nosotros updated our search to 20 February 2018. We made modest changes to update the Background.

Notes

This review will no longer be updated as in that location are no completed or ongoing randomised controlled trials evaluating treatments for mail service‐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, Information Specialist, Ms. Janet Lear, Ambassador, Ms. Laura CI MacDonald, Managing Editor, and Ms. Helen Wakeford, Deputy Managing Editor, all of Cochrane Oral Health. We thank Philip Riley and Ruth Floate for their comments. We also thank Ms. Shazana Binti Mohd Selva, Principal 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 Pedagogy, Melaka, Malaysia, and Professor Dr. Ravi Kant, Vice Chancellor, Male monarch George's Medical University, Lucknow, India for all the suggestions and help during the review training. We also thank Dr. Naresh Yedthare Shetty, Senior Lecturer, International Medical University, Kuala Lumpur for his valuable suggestions.

We acknowledge the help of foreign language 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

1. ((tooth or teeth or molar* or bicuspid* or cuspid* or incisor*):ti,ab) AND (INREGISTER)

2. ((extract* or remov* or surgery):ti,ab) AND (INREGISTER)

3. (#i and #two) AND (INREGISTER)

4. ((drain* or "blood loss" or hemorrhag* or haemorrhag* or hemorrag* or haemorrag*):ti,ab) AND (INREGISTER)

5. (#3 and #4) AND (INREGISTER)

Appendix 2. The Cochrane Central Register of Controlled Trials (CENTRAL) search strategy

#1 [mh ^"Tooth extraction"]
#2 [mh Tooth]
#3 (tooth or teeth or tooth* or bicuspid* or cuspid* or incisor*)
#iv [mh ^"Tooth, impacted"]
#5 {or #2‐#4}
#6 (excerpt* or remov* or surgery)
#7 #v and #6
#8 #one or #7
#9 [mh ^"Blood loss, surgical"]
#10 [mh ^"Postoperative hemorrhage"]
#11 [mh ^"Hemorrhagic disorders"]
#12 [mh ^"Oral hemorrhage"]
#xiii (drain* or "blood loss" or hemorrhag* or haemorrhag* or hemorrag* haemorrag*)
#14 {or #9‐#13}
#xv #eight and #14

Appendix 3. MEDLINE Ovid search strategy

1. Tooth extraction/
2. exp Tooth/
3. (tooth or teeth or molar$ or bicuspid$ or cuspid$ or incisor$).ti,ab.
4. Tooth, impacted/
5. or/2‐4
6. (excerpt$ or remov$ or surgery).ti,ab.
seven. 5 and 6
8. i or 7
nine. Blood loss, surgical/
10. Postoperative hemorrhage/
11. Hemorrhagic disorders/
12. Oral hemorrhage/
thirteen. (drain$ or "blood loss" or hemorrhag$ or haemorrhag$ or hemorrag$ or haemorrag$).ti,ab.
14. or/9‐13
xv. eight and 14

This field of study 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 vi.4.11.1 and detailed in box 6.4.c of The Cochrane Handbook for Systematic Reviews of Interventions, Version five.one.0 [updated March 2011] (Lefebvre 2011).

1. randomized controlled trial.pt.
ii. controlled clinical trial.pt.
3. randomized.ab.
4. placebo.ab.
five. drug therapy.fs.
6. randomly.ab.
7. trial.ab.
8. groups.ab.
nine. or/1‐viii
ten. exp animals/ non humans.sh.
11. 9 not ten

Appendix 4. Embase Ovid search strategy

ane. Tooth extraction/
2. exp Tooth/
three. (tooth or teeth or tooth$ or bicuspid$ or cuspid$ or incisor$).ti,ab.
4. 2 or 3
5. (excerpt$ or remov$ or surgery).ti,ab.
vi. 4 and 5
7. 1 or 6
viii. Bleeding/
9. Bleeding disorder/
x. Oral haemorrhage/
11. (bleed$ or "blood loss" or hemorrhag$ or haemorrhag$ or hemorrag$ or haemorrag$).ti,ab.
12. or/8‐11
13. vii and 12

This subject search was linked to an adapted version of the Cochrane Centralised Search Project filter for identifying RCTs in Embase Ovid (see http://www.cochranelibrary.com/help/key‐cosmos‐details.html for information):

ane. Randomized controlled trial/
2. Controlled clinical study/
3. Random$.ti,ab.
4. randomization/
5. intermethod comparison/
half-dozen. placebo.ti,ab.
7. (compare or compared or comparing).ti.
viii. ((evaluated or evaluate or evaluating or assessed or assess) and (compare or compared or comparing or comparison)).ab.
9. (open adj characterization).ti,ab.
10. ((double or single or doubly or singly) adj (bullheaded or blinded or blindly)).ti,ab.
11. double blind procedure/
12. parallel grouping$i.ti,ab.
13. (crossover or cross over).ti,ab.
14. ((assign$ or match or matched or allotment) adj5 (alternate or group$1 or intervention$i or patient$one or subject$1 or participant$ane)).ti,ab.
15. (assigned or allocated).ti,ab.
16. (controlled adj7 (report or blueprint or trial)).ti,ab.
17. (volunteer or volunteers).ti,ab.
eighteen. trial.ti.
19. or/i‐18
20. (exp animal/ or animal.hw. or nonhuman/) not (exp human/ or man prison cell/ or (homo or humans).ti.)
21. 19 not 20

Appendix five. CINAHL EBSCO search strategy

S13 S8 and S12
S12 S9 or S10 or S11
S11 (bleed* or "blood 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 "Molar, Impacted")
S3 (tooth or teeth or molar* or bicuspid* or cuspid* or incisor*)
S2 (MH "Tooth+")
S1 (MH "Tooth Extraction")

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

S1 MH Random Assignment or MH Single‐blind Studies or MH Double‐blind Studies or MH Triple‐blind Studies or MH Crossover design or MH Factorial Design
S2 TI ("multicentre report" or "multicenter study" or "multi‐centre study" or "multi‐center study") or AB ("multicentre written report" or "multicenter study" or "multi‐centre study" or "multi‐center study") or SU ("multicentre report" or "multicenter study" or "multi‐centre written report" or "multi‐center 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 cantankerous‐over) or SU (crossover or cross‐over)
S6 MH Placebos
S7 AB (singl* or doubl* or trebl* or tripl*) or TI (singl* or doubl* or trebl* or tripl*)
S8 TI blind* or AB mask* or AB blind* 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 6. 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 7. The WHO International Clinical Trials Registry Platform search strategy

Oral surgery and bleed

Oral surgery and hemorrhage

Oral surgery and haemorrhage

Tooth extraction and bleed

Molar extraction and hemorrhage

Tooth extraction and bleeding

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

Trial identification	Title	Language	Translator/s	Reasons for rejection
Trentalancia 1967	The utilize of v‐oxytryptamine in post‐extraction haemorrhages	Italian	Giovanni Lodi	i. The study is non randomised. Randomisation is never mentioned. The author stated that "the patients take been divided every bit follows" (page 1386). two. Patients were at risk of bleeding, and non with post‐extraction bleeding.
Pavek 1976	Evaluation of the haemostatic result of Dicynon in dentoalveolar surgery	Czech	Andrea Pokorna	The study does non fulfil criteria as it describes application of Dicynone in four groups of patients – no randomisation, no detailed description of the patient groups.
Szpirglas 1979	Stomatological haemorrhages; haemostasis with GRF (gelatin‐resorcin‐formol)	Italian	Maddalena Manfredi	This report is a clarification of a topical haemostasis technique without whatever report about patients.
Marini 1966	Therapy of post‐extraction haemorrhages in haemophiliac patients with epsilon‐aminocaproic acid (EACA).	Italian	Maddalena Manfredi	This is a case series.
Torteli 1965	Apply of "reptilase" in postoperative haemorrhage of the dental apparatus	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 bleeding after 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 ii arms; however, the randomisation method is non reported. This is a preventive report for reducing mail service‐extraction complications including PEB, instead of managing mail service‐extraction bleeding.
Antoszewski 1972	Cepevit‐1000 training in controlling haemorrhages and bleeding following molar extraction	Polish	Joanna Zajac and Malgorzata Bala	Not a randomised controlled trial. They used Cepevit‐K: ‐ later extraction for 22 patients (for 17, bleeding was stopped inside eight minutes; chirurgical treatment was provided for the others). ‐ two days before extraction in xviii patients with depression coagulation time (for four patients in this group, boosted chirurgical treatment was needed). The merely comparison is twenty other people with haemorrhage after tooth extraction, where the author used other techniques (other than chirurgical treatment); information technology only worked for eight patients, so the other 12 were given Cepevit‐Grand.
Fetkowska‐Mielnik 1969	Clinical evaluation of the results of handling of postal service‐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 blood coagulation problems: some subsequently extraction with bleeding, some before extraction. For all blood analyses were done and according to results: ‐ for some: epsilon aminocaproic acid (EACA) was used ‐ for others: Styptanon was used ‐ for others: EACA and Styptanon together
Khomiachenko 1978	Employ of aminocaproic acid for stopping the haemorrhage afterward tooth extraction	Russian	Lilia Ziganshina and Anna Misyail Abdul Rashid	This is an abstract describing 100% success of five% aminocapronic acrid in 135 patients. This was not a trial; at that place was no comparison.
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 mail‐extraction bleeding are explained in detail, but not inside the scope of a clinical written report.
Saltykova 1974	The employ of new haemostatic drug in dental practice	Russian	Lilia Ziganshina and Anna Misyail Abdul Rashid	This is a single case study.
Martineau 1989	Hemorrhage in the dental office. Study of local haemostatic treatment	French	Paul Tramini	This paper is simply 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	Polish	Joanna Zajac and Malgorzata Bala	This commodity is not a RCT. All participants (13 children with haemophilia: nine blazon A and four type B) received epsilon‐aminocaproic (twenty% solution) acrid 24 hours before tooth extraction. Intolerance developed in some children, then the dose was changed (from 0.i g/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 as 'managing' could be interpreted as including prevention, which was not our intention.

Figure 1 in the protocol has been modified to Table one in the review ('Types of bleeding later dental extractions').

Primary and secondary outcomes are re‐worded without changing the meaning.

Nosotros had mentioned under selection of studies that two pairs of review authors would independently screen the titles and abstracts to identify potentially eligible studies. Withal, three pairs of review authors screened the titles and abstracts.

As we did non have whatever included trials, the contribution of authors differed from what nosotros had planned.

Contributions of authors

• Sumanth Kumbargere Nagraj: drafting the protocol, evaluation of total 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 full text articles for inclusion or exclusion and updating the review.

• Himanshi Aggarwal: drafting the protocol, screening titles and abstracts, and drafting the last review.

• Ashok Lingappa: content expert, screening titles and abstracts.

• Murugan Southward Muthu: content practiced, screening titles and abstracts, and drafting the concluding review.

• Salian Kiran Kumar Krishanappa: undertaking searches, screening titles and abstracts.

• Haszelini Hassan: content skilful, screening titles and abstracts, and drafting the last review.

Sources of support

Internal sources

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

  Library back up and providing training in Cochrane Systematic Reviews

External sources

• National Institute for Health Research (NIHR), UK.

  This projection 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 practice not necessarily reflect those of the Systematic Reviews Programme, NIHR, NHS or the Department of Health.

• Cochrane Oral Health Global Alliance, Other.

  The production of Cochrane Oral Wellness reviews has been supported financially past 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; Equally‐Akademie, Germany; the British Association for the Study of Community Dentistry, United kingdom; the British Club of Paediatric Dentistry, UK; the Canadian Dental Hygienists Association, Canada; the Heart for Dental Instruction and Research at All Bharat Institute of Medical Sciences, India; the National Heart for Dental Hygiene Enquiry & Practice, The states; New York Academy College of Dentistry, U.s.a.; and NHS Didactics for Scotland, United kingdom of great britain and northern ireland; Swiss Social club of Endodontology, Switzerland.

Declarations of involvement

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 S Muthu: no interests to declare
Salian Kiran Kumar Krishanappa: no interests to declare
Haszelini Hassan: no interests to declare

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6494262/

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