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Kumbargere Nagraj S, Eachempati P, Paisi M, Nasser M, Sivaramakrishnan G, Francis T, Verbeek JH. Preprocedural mouth rinses for preventing transmission of infectious diseases through aerosols in dental healthcare providers. Cochrane Database Syst Rev 2022; 8:CD013826. [PMID: 35994295 PMCID: PMC9394685 DOI: 10.1002/14651858.cd013826.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Aerosols and spatter are generated in a dental clinic during aerosol-generating procedures (AGPs) that use high-speed hand pieces. Dental healthcare providers can be at increased risk of transmission of diseases such as tuberculosis, measles and severe acute respiratory syndrome (SARS) through droplets on mucosae, inhalation of aerosols or through fomites on mucosae, which harbour micro-organisms. There are ways to mitigate and contain spatter and aerosols that may, in turn, reduce any risk of disease transmission. In addition to personal protective equipment (PPE) and aerosol-reducing devices such as high-volume suction, it has been hypothesised that the use of mouth rinse by patients before dental procedures could reduce the microbial load of aerosols that are generated during dental AGPs. OBJECTIVES To assess the effects of preprocedural mouth rinses used in dental clinics to minimise incidence of infection in dental healthcare providers and reduce or neutralise contamination in aerosols. SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search date was 4 February 2022. SELECTION CRITERIA We included randomised controlled trials and excluded laboratory-based studies. Study participants were dental patients undergoing AGPs. Studies compared any preprocedural mouth rinse used to reduce contaminated aerosols versus placebo, no mouth rinse or another mouth rinse. Our primary outcome was incidence of infection of dental healthcare providers and secondary outcomes were reduction in the level of contamination of the dental operatory environment, cost, change in mouth microbiota, adverse events, and acceptability and feasibility of the intervention. DATA COLLECTION AND ANALYSIS Two review authors screened search results, extracted data from included studies, assessed the risk of bias in the studies and judged the certainty of the available evidence. We used mean differences (MDs) and 95% confidence intervals (CIs) as the effect estimate for continuous outcomes, and random-effects meta-analysis to combine data MAIN RESULTS: We included 17 studies with 830 participants aged 18 to 70 years. We judged three trials at high risk of bias, two at low risk and 12 at unclear risk of bias. None of the studies measured our primary outcome of the incidence of infection in dental healthcare providers. The primary outcome in the studies was reduction in the level of bacterial contamination measured in colony-forming units (CFUs) at distances of less than 2 m (intended to capture larger droplets) and 2 m or more (to capture droplet nuclei from aerosols arising from the participant's oral cavity). It is unclear what size of CFU reduction represents a clinically significant amount. There is low- to very low-certainty evidence that chlorhexidine (CHX) may reduce bacterial contamination, as measured by CFUs, compared with no rinsing or rinsing with water. There were similar results when comparing cetylpyridinium chloride (CPC) with no rinsing and when comparing CPC, essential oils/herbal mouthwashes or boric acid with water. There is very low-certainty evidence that tempered mouth rinses may provide a greater reduction in CFUs than cold mouth rinses. There is low-certainty evidence that CHX may reduce CFUs more than essential oils/herbal mouthwashes. The evidence for other head-to-head comparisons was limited and inconsistent. The studies did not provide any information on costs, change in micro-organisms in the patient's mouth or adverse events such as temporary discolouration, altered taste, allergic reaction or hypersensitivity. The studies did not assess acceptability of the intervention to patients or feasibility of implementation for dentists. AUTHORS' CONCLUSIONS: None of the included studies measured the incidence of infection among dental healthcare providers. The studies measured only reduction in level of bacterial contamination in aerosols. None of the studies evaluated viral or fungal contamination. We have only low to very low certainty for all findings. We are unable to draw conclusions regarding whether there is a role for preprocedural mouth rinses in reducing infection risk or the possible superiority of one preprocedural rinse over another. Studies are needed that measure the effect of rinses on infectious disease risk among dental healthcare providers and on contaminated aerosols at larger distances with standardised outcome measurement.
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Affiliation(s)
- Sumanth Kumbargere Nagraj
- Professor and Head, Department of Oral Medicine and Oral Radiology, Faculty of Dentistry, Manipal University College Malaysia, Melaka, Malaysia
- Honorary Research Fellow, Division of Surgery and Interventional Science, Department of Surgical Biotechnology, University College London, London, UK
| | - Prashanti Eachempati
- Professor and Head, Department of Prosthodontics, Faculty of Dentistry, Manipal University College Malaysia, Melaka, Malaysia
| | - Martha Paisi
- Peninsula Dental Social Enterprise, Peninsula Dental School, University of Plymouth, Plymouth, UK
| | - Mona Nasser
- Peninsula Dental School, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | | | - Tony Francis
- Department of Conservative Dentistry and Endodontics, Faculty of Dentistry, Manipal University College Malaysia, Melaka, Malaysia
| | - Jos H Verbeek
- Cochrane Work, Department of Public and Occupational Health, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
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Martín-Quintero I, Cervera-Sabater A, Tapias-Perero V, Nieto-Sánchez I, de la Cruz-Pérez J. Air particulate concentration during orthodontic procedures: a pilot study. BMC Oral Health 2021; 21:361. [PMID: 34289851 PMCID: PMC8293529 DOI: 10.1186/s12903-021-01725-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 07/08/2021] [Indexed: 11/10/2022] Open
Abstract
Background This study evaluates the particle dispersion involved in dental procedures carried out during orthodontic treatments. Variants such as temperature and relative humidity in the dental cabinet were considered. Methods Using a particle counter, a pilot study was conducted, in which 98 consecutive recordings were made during appointments of patients undergoing orthodontic treatments. Temperature, relative humidity and particles present at the beginning (AR) and during the appointment (BR) were recorded. A control record (CR) of temperature, relative humidity and particles present was made before the start of the clinical activity. In addition to conventional statistics, differential descriptive procedures were used to analyse results, and the influence of relative humidity on particle concentration was analysed by statistical modelling with regression equations. Results The number of particles present, regardless of their size, was much higher in AR than in CR (p < .001). The same was true for relative humidity and ambient temperature. The relationship between relative humidity and particle number was determined to be exponential. Limitations of the study The limitations are associated with sample size, environmental conditions of the room and lack of discrimination among the procedures performed. Conclusions This pilot study shows that from the moment a patient enters a dental office, a large number of additional particles are generated. During treatment, the number of particles of 0.3 microns—which have a high capacity to penetrate the respiratory tract-increases. Moreover, a relationship between relative humidity and particle formation is observed. Further studies are needed.
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Affiliation(s)
- Inmaculada Martín-Quintero
- Department of Orthodontics, Universidad Alfonso X El Sabio, Madrid, Spain. .,Centro Odontológico de Innovación y Especialidades Avanzadas, Calle de Albarracín, 35, 28037, Madrid, Spain.
| | | | | | - Iván Nieto-Sánchez
- Department of Orthodontics, Universidad Alfonso X El Sabio, Madrid, Spain
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Mohd-Said S, Mohd-Dom TN, Suhaimi N, Rani H, McGrath C. Effectiveness of Pre-procedural Mouth Rinses in Reducing Aerosol Contamination During Periodontal Prophylaxis: A Systematic Review. Front Med (Lausanne) 2021; 8:600769. [PMID: 34179030 PMCID: PMC8222587 DOI: 10.3389/fmed.2021.600769] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 04/13/2021] [Indexed: 12/14/2022] Open
Abstract
Background: Aerosol-producing dental procedures are of concern in the spread of infections, especially during the COVID-19 pandemic. Periodontal prophylaxis is the most common aerosol-producing procedure conducted in dental practice globally. During COVID-19, many national and international organizations advocated the use of pre-procedural mouth rinsing to prevent the spread of infections from aerosol-generating procedures in the dental setting; however, many questioned the scientific basis for such recommendations. Objective: This systematic review aimed to evaluate the effectiveness of pre-procedural rinsing when preforming periodontal prophylaxis in reducing aerosol contamination in the dental setting. Methods: A comprehensive standardized search strategy was employed, informed by a defined PICO question across four electronic databases. The review of the literature was conducted using the PRISMA framework. Agreement between assessors was determined throughout. Synthesis of study characteristics and key outcomes were conducted. Cochrane's risk-of-bias tool for randomized trials (RoB 2) was employed to assess the quality/bias among studies. Results: The initial search yielded 731 citations across the four databases; 95 potentially effective studies were identified, with 56 effective studies found. Thirty randomized control trial studies were identified, 21 with a focus on effectiveness of pre-procedural mouth rinsing, involving 984 participants (aged 18-70). Agreement between assessors was high (Kappa >0.80). Various pre-procedural mouth rinses were tested, most frequently chlorhexidine (CHX) in 18 studies. The concentrations, volume, and prescribed duration of rinsing varied among studies, hampering meta-analyses. Nonetheless, all studies identified significant reductions in bacterial contamination, as measured by colony forming units (cfu). The effectiveness of CHX over other agents was evident with more than half of the studies (7/15) reporting over a 70% reduction in bacterial contamination (cfu). There were concerns over the risk of bias in most studies (76.2%); 19.0% had a high risk of bias and 4.8% were of low risk of bias. Conclusion: There is substantial evidence to support pre-procedural mouth rinsing, such as with chlorohexidine, to effectively reduce aerosol contamination when performing periodontal prophylaxis compared to mouth rinsing with water or not rinsing.
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Affiliation(s)
- Shahida Mohd-Said
- Faculty of Dentistry, Universiti Kebangsaan Malaysia (The National University of Malaysia), Kuala Lumpur, Malaysia
| | - Tuti Ningseh Mohd-Dom
- Faculty of Dentistry, Universiti Kebangsaan Malaysia (The National University of Malaysia), Kuala Lumpur, Malaysia
| | - Nawal Suhaimi
- Faculty of Dentistry, Universiti Kebangsaan Malaysia (The National University of Malaysia), Kuala Lumpur, Malaysia
| | - Haslina Rani
- Faculty of Dentistry, Universiti Kebangsaan Malaysia (The National University of Malaysia), Kuala Lumpur, Malaysia
| | - Colman McGrath
- Faculty of Dentistry, Universiti Kebangsaan Malaysia (The National University of Malaysia), Kuala Lumpur, Malaysia
- Faculty of Dentistry, The University of Hong Kong, Sai Ying Pun, Hong Kong
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Johnson IG, Jones RJ, Gallagher JE, Wade WG, Al-Yaseen W, Robertson M, McGregor S, K C S, Innes N, Harris R. Dental periodontal procedures: a systematic review of contamination (splatter, droplets and aerosol) in relation to COVID-19. BDJ Open 2021; 7:15. [PMID: 33762575 PMCID: PMC7988384 DOI: 10.1038/s41405-021-00070-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 02/20/2021] [Accepted: 03/01/2021] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION The emergence of the SARS-CoV-2 virus and subsequent COVID-19 pandemic has had a significant effect on the delivery of routine dentistry; and in particular, periodontal care across the world. This systematic review examines the literature relating to splatter, droplet settle and aerosol for periodontal procedures and forms part of a wider body of research to understand the risk of contamination in relation to periodontal care procedures relevant to COVID-19. METHODS A search of the literature was carried out using key terms and MeSH words relating to the review questions. Sources included Medline (OVID), Embase (OVID), Cochrane Central Register of Controlled Trials, Scopus, Web of Science and LILACS, ClinicalTrials.Gov . Studies meeting inclusion criteria were screened in duplicate and data extraction was carried out using a template. All studies were assessed for methodological quality and sensitivity. Narrative synthesis was undertaken. RESULTS Fifty studies were included in the review with procedures including ultrasonic scaling (n = 44), air polishing (n = 4), prophylaxis (n = 2) and hand scaling (n = 3). Outcomes included bacterial (colony-forming units e.g. on settle plates) or blood contamination (e.g. visible splatter) and non bacterial, non blood (e.g. chemiluminescence or coloured dyes) contamination. All studies found contamination at all sites although the contamination associated with hand scaling was very low. Contamination was identified in all of the studies even where suction was used at baseline. Higher power settings created greater contamination. Distribution of contamination varied in relation to operator position and was found on the operator, patient and assistant with higher levels around the head of the operator and the mouth and chest of the patient. Settle was identified 30 min after treatments had finished but returned to background levels when measured at or after an hour. The evidence was generally low to medium quality and likely to underestimate contamination. CONCLUSION Ultrasonic scaling, air polishing and prophylaxis procedures produce contamination (splatter, droplets and aerosol) in the presence of suction, with a small amount of evidence showing droplets taking between 30 min and 1 h to settle. Consideration should be given to infection control, areas of cleaning particularly around the patient and appropriate personal protective equipment, with particular attention to respiratory, facial and body protection for these procedures. In addition, the use of lower power settings should be considered to reduce the amount and spread of contamination.
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Affiliation(s)
- Ilona G Johnson
- Cardiff University School of Dentistry, Applied Clinical Research and Public Health, College of Biomedical and Life Sciences, Heath Park, Cardiff, UK.
| | - Rhiannon J Jones
- Cardiff University School of Dentistry, Dental Education, Scholarship & Innovation, College of Biomedical and Life Sciences, Heath Park, Cardiff, UK
| | - Jennifer E Gallagher
- Faculty of Dentistry, Oral & Craniofacial Sciences, King's College London, Denmark Hill Campus, Bessemer Road, London, UK
| | | | - Waraf Al-Yaseen
- School of Dentistry, College of Biomedical and Life Sciences, Cardiff University, Heath Park, Cardiff, UK
| | - Mark Robertson
- School of Dentistry, Child Dental and Oral Health, University of Dundee, Dundee, UK
| | - Scott McGregor
- Library and Learning Centre, University of Dundee, Dundee, UK
| | - Sukriti K C
- Faculty of Dentistry, Oral & Craniofacial Surgery, King's College London, Centre for Host Microbiome Interactions, Denmark Hill Campus, Bessemer Road, London, UK
| | - Nicola Innes
- School of Dentistry, College of Biomedical and Life Sciences, Cardiff University, Heath Park, Cardiff, UK
| | - Rebecca Harris
- Department of Public Health, Policy & Systems, University of Liverpool, Room 124, 1st Floor, Block B, Waterhouse Building, Liverpool, UK
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Koletsi D, Belibasakis GN, Eliades T. Interventions to Reduce Aerosolized Microbes in Dental Practice: A Systematic Review with Network Meta-analysis of Randomized Controlled Trials. J Dent Res 2020; 99:1228-1238. [PMID: 32660314 DOI: 10.1177/0022034520943574] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
The aim of this systematic review and network meta-analysis was to identify and rank the effectiveness of different interventions used in dental practice to reduce microbial load in aerosolized compounds. Seven electronic databases were searched to April 6, 2020, for randomized controlled trials (RCTs) or nonrandomized prospective studies in the field. Study selection, data extraction, and risk-of-bias assessment were performed for all included studies, while the outcome of interest pertained to differences in bacterial load quantification through the use of different interventions prior to aerosol-generating procedures in dental practices. Random effects frequentist network meta-analysis was performed, with mean difference (MD) and 95% CI as the effect measure. Confidence in the documented evidence was assessed through the newly fueled CINeMA framework (Confidence in Network Meta-analysis) based on the GRADE approach (Grading of Recommendations, Assessment, Development and Evaluation). Twenty-nine clinical trials were deemed eligible, 21 RCTs and 8 nonrandomized studies, while 11 RCTs contributed to the network meta-analysis, comprising 10 competing interventions. Tempered chlorhexidine (CHX) 0.2% as compared with nonactive control mouth rinse, prior to routine ultrasonic scaling, was most effective toward reduced postprocedural bacterial load with an MD of -0.92 (95% CI, -1.54 to -0.29) in log10 bacterial CFUs (colony-forming units). For CHX 0.2%, an MD of -0.74 (95% CI, -1.07 to -0.40) was observed as compared with control. Tempered CHX 0.2% presented the highest probabilities of being ranked the most effective treatment (31.2%). Level of confidence varied from very low to moderate across all formulated comparisons. These findings summarize the current state of research evidence in the field of aerosolized bacteria in dentistry. Instigated by the era of SARS-CoV-2 pandemic, the stipulation of a broader evaluation of the aerosolized microbes, including viruses, potentially coupled with disinfectant-based prevention schemes should be prioritized.
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Affiliation(s)
- D Koletsi
- Clinic of Orthodontics and Pediatric Dentistry, Center of Dental Medicine, University of Zurich, Zurich, Switzerland
| | - G N Belibasakis
- Division of Oral Diseases, Department of Dental Medicine, Karolinska Institutet, Huddinge, Sweden
| | - T Eliades
- Clinic of Orthodontics and Pediatric Dentistry, Center of Dental Medicine, University of Zurich, Zurich, Switzerland
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Dental Considerations After the Outbreak of 2019 Novel Coronavirus Disease: A Review of Literature. ARCHIVES OF CLINICAL INFECTIOUS DISEASES 2020. [DOI: 10.5812/archcid.103257] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Marui VC, Souto MLS, Rovai ES, Romito GA, Chambrone L, Pannuti CM. Efficacy of preprocedural mouthrinses in the reduction of microorganisms in aerosol: A systematic review. J Am Dent Assoc 2019; 150:1015-1026.e1. [PMID: 31761015 DOI: 10.1016/j.adaj.2019.06.024] [Citation(s) in RCA: 125] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 06/12/2019] [Accepted: 06/15/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND The authors of this systematic review aimed to evaluate the efficacy of preprocedural mouthrinses in reducing the number of microorganisms disseminated by means of the aerosol generated via dental procedures when compared with a placebo, water, or no mouthrinse. TYPES OF STUDIES REVIEWED The authors included only randomized clinical trials. They searched MEDLINE (PubMed), Embase, Google Scholar, and Latin American and Caribbean Health Sciences Literature databases through May 31, 2019. They performed random-effects meta-analysis for reduction of the number of colony-forming units (CFU) in the dental aerosol. RESULTS Of 770 potentially relevant articles, the authors included 13 randomized clinical trials in which researchers studied the efficacy of chlorhexidine, essential oils, cetylpyridinium chloride, and herbal products. Meta-analysis of 12 studies showed that mouthrinses with chlorhexidine, essential oils, and cetylpyridinium chloride significantly reduced the number of CFU. Overall, the use of a preprocedural mouthrinse resulted in a mean reduction in the number of CFUs of 64.8% (95% confidence interval, 50.4% to 79.3%; I2 = 37%) compared with control. None of the included studies presented a low risk of bias. PRACTICAL IMPLICATIONS Some dental procedures result in dissemination of microorganisms in the aerosol in the dental office. There is moderate evidence that preprocedural mouthrinses significantly reduce the number of microorganisms in the dental aerosol.
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Paul B, Baiju RMP, Raseena NB, Godfrey PS, Shanimole PI. Effect of aloe vera as a preprocedural rinse in reducing aerosol contamination during ultrasonic scaling. J Indian Soc Periodontol 2019; 24:37-41. [PMID: 31983843 PMCID: PMC6961450 DOI: 10.4103/jisp.jisp_188_19] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 05/13/2019] [Accepted: 06/05/2019] [Indexed: 11/29/2022] Open
Abstract
Background: The use of preprocedural mouth rinse is one of the recommended ways to reduce aerosol contamination during ultrasonic scaling. Different agents have been tried as preprocedural mouth rinse. Chlorhexidine and povidone-iodine significantly reduce the viable microbial content of aerosol when used as a preprocedural rinse. Studies have shown that aloe vera (AV) mouthwash is equally effective as chlorhexidine in reducing plaque and gingivitis. There is no published literature on the role of AV as a preprocedural mouth rinse. Hence, this study compared the effect of 94.5% AV to 0.2% chlorhexidine gluconate (CHX) and 1% povidone-iodine (PVP-I) as preprocedural mouth rinses in reducing the aerosol contamination by ultrasonic scaling. Materials and Methods: Sixty subjects were divided into three groups based on the preprocedural rinse use (0.2% CHX, 1% PVP-I, and 94.5% AV). Ultrasonic scaling was done for 20 min in the same closed operatory for all the subjects after keeping blood agar plates open at two standardized locations. Colony forming units (CFUs) on blood agar plates were counted, and predominant bacteria were identified after incubation at 37°C for 48 h. Results: There was statistically significant difference in the CFU counts between CHX group and PVP-I group and between AV group and PVP-I group. There was no difference between CHX group and AV group at both the locations. Conclusion: 94.5% AV as a preprocedural rinse is better than 1% PVP-I and comparable to 0.2% CHX in reducing CFU count.
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Affiliation(s)
- Benna Paul
- Department of Periodontics, Government Dental College, Kottayam, Kerala, India
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Muniz de Oliveira R, da Rosa Gioppo NM, Oliveira de Carvalho J, Carvalho Oliveira F, Webster TJ, Marciano FR, Oliveira Lobo A. Decontamination of mobile phones and electronic devices for health care professionals using a chlorhexidine/carbomer 940® gel. Front Chem Sci Eng 2018. [DOI: 10.1007/s11705-018-1728-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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[Not Available]. Orthod Fr 2016; 87:119-49. [PMID: 27083237 DOI: 10.1051/orthodfr/2016002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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