Showing papers in "Evidence-based Dentistry in 2007"

Study design VII. Randomised controlled trials.

Abstract: Previously in this series, I have given an overview of the main types of study design and the techniques used to minimise the likelihood of obtaining biased results. In this article I describe more fully randomised controlled trials, their uses, advantages and limitations.

Benchmarking of reported search and selection methods of systematic reviews by dental speciality

Abstract: Previous evaluations showed that literature-search and selection methods reported in dental systematic reviews (SR) have improved since 2000. It is not known, however, whether these differences are consistent between the SR of the different dental specialities. SR in dentistry published in the English language between 1 January 2000 and 14 June 2006 were located and then categorised by American Dental Association (ADA) recognised specialities. Search and selection methods were evaluated following an adaptation of the Cochrane Handbook for Systematic Reviews. Search and selection methods between dental specialities were compared using Pearson's chi-squared analysis and ranked. There were significant differences between specialities in the following criteria: documentation of search dates (P 0.003); inclusion–exclusion documentation (P 0.017); article selection by two or more reviewers (P 0.001); and inclusion of all languages (P 0.014). Periodontics SR met the most criteria followed by oral and maxillofacial surgery (OMS) and then dental public heath (DPH). Prosthodontics along with the area of oral and maxillofacial radiology (OMR) met the fewest. All dental SR had low compliance with four criteria, only 65.7% searched more than Medline, 50.4% had a search strategy documented with Boolean operators, 51.5% had article selection carried out by two or more reviewers and only 25.7% included all languages. Some dental specialities are better at reporting search and selection methods than others but all dental SR need some improvement in their reporting.

Types of data

Abstract: In most, if not all, studies we collect data to obtain information about an area of research in which we have an interest. For example, we might want to know the level of dental caries in our area. In order to discover this we might need to observe a number of different variables, which could include, age, sex, number of teeth, cavities, fillings, extraction, pain, sepsis and quality of life. This information or data is normally obtained from a sample of the population which can then be summarised, analysed and conclusions drawn. This collection, summarising and analysis of data are what statistics and statistical technique are all about.

Periodontal treatment in pregnant women improves periodontal disease but does not alter rates of preterm birth

Abstract: This was a multicentre randomised controlled trial (RCT). Pregnant women were divided into two groups. Those to whom dental treatment was given had up to four visits of periodontal scaling and root planing using ultrasonic and hand instruments, with local anaesthesia as needed. Treatment recipients were also given instruction in oral hygiene and monthly tooth polishing and re-instruction in oral hygiene, with scaling and planing as needed. Control patients received only a brief oral examination at monthly follow-ups but attended the same number of visits as the treatment group. Patients in the control group were offered the same periodontal therapy after delivery. The primary outcome was gestational age at delivery. Secondary outcomes included birth weight, the proportion of infants who were small for gestational age, Apgar scores, and admissions to a neonatal intensive care unit. Preterm birth (before 37 weeks of gestation) occurred in 49 out of 407 women (12.0%) in the treatment group (resulting in 44 live births) and in 52 out of 405 women (12.8%) in the control group (resulting in 38 live births). Although periodontal treatment improved periodontitis measures (P<0.001), it did not significantly alter the risk of preterm delivery [P 0.70; hazard ratio for treatment group versus control group, 0.93; 95% confidence interval (CI), 0.63–1.37]. There were no significant differences between the treatment and control groups in mean babies' birth weights (3239 g versus 3258 g; P 0.64) or in the rate of delivery of infants who were small for gestational age (12.7% versus 12.3%; odds ratio, 1.04; 95% CI, 0.68–1.58). There were five spontaneous abortions or stillbirths in the treatment group, compared with 14 in the control group (P 0.08). Treatment of periodontitis in pregnant women improves periodontal disease and is safe but does not significantly alter rates of preterm birth, low birth weight or foetal growth restriction.

Each portion of fruit or vegetable consumed halves the risk of oral cancer.

Abstract: Medline was used to find relevant papers; reference lists of retrieved publications were also searched. Studies were included if they met all of the following criteria: 1) they contained original data from case–control or cohort studies; 2) the primary outcome was clearly defined as cancers of the mouth, pharynx and hypopharynx (as defined by codes 141, 143–146,148 and 149 of the ninth revision of the International Classification of Diseases or other classifications that included these sites); 3) the exposure of interest was measured as servings (per day, week or month) of fruit, vegetables or both (other exposure measurements, such as mass per day, were excluded unless data were provided to transform information to servings per day); 4) they provided relative risk (RR) estimates and their 95% confidence intervals (CI), or sufficient data to calculate these parameters; 5) were published in the English language; and 6) were published before September 2005. If a study appeared in more than one article, data from the most recent publication were used for the statistical analysis. Studies restricted to oral cancer in subjects aged under 45 years were excluded. Study quality was assessed and data were extracted independently by two investigators, differences being resolved by discussion. All studies were stratified by fruit or vegetable intake to evaluate any dose–response relations, and some of the studies were used to perform multivariate analyses to adjust for several confounders. Separate meta-analyses were conducted for fruit and vegetable consumption. Potential sources of heterogeneity between the studies were examined using the DerSimonian and Laird method. Sensitivity analyses and a multivariate metaregression analysis were performed to examine observed heterogeneity. A total of 71 potentially relevant studies were identified: 16 were included in the meta-analysis. Seven studies had been carried out in Europe, five in the Americas and four in East Asia. Three case–control studies consisted solely of men and one study consisted solely of women. The pooled data allowed 65 802 and 57 993 subjects, respectively, to be included in analysis of fruit and vegetable consumption. The combined adjusted odds ratio (OR) estimates based on 16 studies showed that each portion of fruit consumed per day had a statistically significant effect, reducing the risk of oral cancer by 49% (OR, 0.51; 95% CI, 0.40–0.65). A similar effect was seen for vegetable consumption, with a significant reduction in the risk of oral cancer of 50% (OR, 0.50; 95% CI, 0.38–0.65). Homogeneity testing found a statistically significant heterogeneity for fruit consumption and vegetable consumption studies. This was examined using sensitivity analysis which did not substantially modify the main findings of the meta-analysis. The consumption of fruit and vegetables was found to be associated with a reduced risk of oral cancer. Prospective studies are needed to confirm this result.

Better outcomes in pulpotomies on primary molars with MTA.

Abstract: Medline, Cochrane Library, Embase, Science Citation Index and the China National Knowledge Infrastructure were used to source articles. In addition, identified papers' reference lists and their authors' other published literature were also scanned. Studies of interest were randomised controlled trials of primary molar teeth where there was exposure of vital pulp caused by caries or trauma, with at least 6 months follow-up. It was required that selected teeth had no internal root resorption, inter-radicular and periapical bone destruction, no periodontal involvement, swelling, or sinus tract; they should be restorable with stainless steel crowns; and that outcomes were evaluated by clinical symptoms and radiographic evidence where the comparison followed a standard definition of success or failure, as shown by the number of teeth. Data were extracted from each study independently and entered into a database. Differences were resolved by discussion. Studies were scored for validity criteria according to the Jadad scale. Meta-analysis was performed using the software RevMan (version 4.2.8; Copenhagen; The Nordic Cochrane Centre, The Cochrane Collaboration, 2003). Heterogeneity between studies was assessed using a standard chi-square test. If there was homogeneity among the studies, the fixed-effect model (Peto method) was applied to aggregate the data. If homogeneity was rejected then sensitivity analyses were performed using a random-effects model. Six studies met the inclusion criteria (giving a total of 381 teeth). There was a significant difference between the success rates of formocresol (FC)- and mineral trioxide aggregate (MTA)-treated pulpotomised primary molars (P<0.05) Clinical assessments and radiographic findings of the MTA versus FC pulpotomy suggested that MTA was superior to FC in pulpotomy, resulting in a lower failure rate [relative risk, 0.32 (95% confidence interval, 0.11–0.90) and 0.31 (95% confidence interval, 0.13–0.74) respectively]. The results demonstrate that in primary molar teeth with vital pulp exposure caused by caries or trauma, a pulpotomy performed with MTA results in better clinically and radiographically observed outcomes. Fewer undesirable responses were recorded for MTA than when FC was used. Therefore, the study supports the use of MTA instead of FC as wound dressing when performing pulpotomies on primary molars.

APF foam does reduce caries in primary teeth.

Abstract: Design A double-blind, cluster randomised, placebo-controlled trial was conducted. Intervention Acidulated phosphate fluoride foam (APF; 1.23%) or placebo (fluoride-free) foam were applied by a dental practitioner twice per year for 2 years. Oral examinations were undertaken at baseline and after 2 years, following World Health Organization criteria for caries diagnosis. Outcome measure Caries increment was evaluated after 2 years. Results In total, 392 children of age 3-4 years were recruited, of whom 209 were randomised to the test group and 183 to the control. One hundred and sixty-seven test and 151 control children completed the study. There was no mean caries increment (measured as decayed, missing or filled primary teeth; dmfs) in 38.3% of test and 26.5% of control group children. The figure for dmfs was 3.8 in the test and 5.0 in the control group (P 0.03). A significant difference was also observed in caries increment on approximal surfaces between test and control groups (P Conclusions Bi-annual professional application of APF foam, over 2 years, was effective in reducing caries increment in primary teeth.

School dental screening does not increase dental attendance rates or reduce disease levels.

Abstract: This was a cluster randomised controlled trial, in which the unit of randomisation was the school. Three models of screening were tested against a control. A ‘new’ model of school dental screening incorporated a consensus view, from clinicians in the northwest of England, on a set of clinical criteria that would prompt a referral following a screening examination. A ‘traditional’ model involved the delivery of the existing school dental screening programme according to the principle that a child is referred if, in the opinion of the screening dentist, dental care is required. The third intervention tested was a dental information leaflet, distributed via the schools, which encouraged parents to examine their child's mouth and to take their child to a dentist if any problems were noted. Children a ttending the control schools received no intervention during the study period. The main outcome measures were prevalence of teeth with active caries and mean number of teeth with active caries in the permanent or primary dentition. Secondary outcome measures were prevalence of oral sepsis, gross plaque or calculus, and dental trauma to incisor teeth. Seventeen thousand and ninety-eight children in 169 clusters (schools) were eligible for inclusion in the study. One school was withdrawn from the study because of failure to agree to follow the trial protocol. Of the total, 15 004 children were available for baseline examination in 168 schools and 13 570 children received a baseline and outcome examination, representing 80.5% of the eligible population. After adjustment for clustering of children in schools, there was no significant difference in the reduction from baseline in untreated caries between the study groups in either the primary or permanent dentition. Similarly there were no significant differences across the four arms of the study in the secondary outcome measures of prevalence of sepsis, presence of gross plaque or calculus, and trauma to the permanent incisor teeth. In the traditional arms, 42% of children attended a dentist during the study period, with 41% in the new-model arm, 37% in the information-leaflet arm and 38% in the control arm. Although more children in the traditional and new-model arms of the study attended a dental appointment these differences were not statistically significant. School dental screening delivered according to three different models was not effective at reducing levels of active caries and increasing dental attendance in the population under study.

The EQUATOR network and website.

Abstract: The quality, reliability and reporting of research is a subject that is regularly raised in the pages of Evidence-based Dentistry. We have constantly sought to highlight the various guidelines available to guide researchers when reporting their research and, consequently, it is pleasing to be able to bring to readers' attention a new group, the EQUATOR Network (Enhancing the QUAlity and Transparency Of health Research). This is a new quality-improvement initiative that seeks to improve the quality and reliability of the health research literature by promoting transparent and accurate reporting through the use of reporting guidelines.

Stannous fluoride toothpastes reduce the gingival index more than sodium fluoride toothpastes.

Abstract: Medline and the Cochrane Central Register of Controlled Trials were used to identify sources of data. Title and abstracts were screened independently. Randomised controlled clinical trials of >6 months duration that used gingivitis or plaque levels as outcome measures were selected. The mean values and standard deviations were extracted. In studies where standard errors of the mean were reported, standard deviations were calculated by the authors based on the sample size. Weighted means of baseline and of end of trial were calculated with the software Cochrane Collaboration Review Manager (version 4.2; The Cochrane Collaboration, Oxford, England) using a random-effects model. A meta-analysis for stannous fluoride (SnF) mouth rinse and dentifrice/ mouthrinse formulations was not performed because there were insufficient data. Fifteen papers were included in the review. For SnF dentifrices, a statistically significant reduction in gingivitis was noted in comparison with control [weighted mean difference (WMD), 0.15 (gingival index) and 0.21 (gingivitis severity index); test for heterogeneity P<0.00001, I2=91.1% and P 50.03, I2= 80.1%, respectively]. There were inconsistent results for plaque reduction. On using the plaque index, no differences were found, whereas meta-analysis of the Turesky index gave a WMD of 0.31 (P 50.01; test for heterogeneity P 0.0001, I2=91.7%). The use of SnF dentifrices results in greater gingivitis and plaque reduction compared with a conventional dentifrice. The precise magnitude of this effect was difficult to assess because of a high level of heterogeneity in study outcomes.

Mineral trioxide aggregate a reliable alternative material for pulpotomy in primary molar teeth. Is mineral trioxide aggregate more effective than formocresol for pulpotomy in primary molars

Abstract: Mineral trioxide aggregate a reliable alternative material for pulpotomy in primary molar teeth

Patient delay in reporting oral cancer is poorly understood.

Abstract: Studies were sourced using databases as follows: Allied and Complementary Medicine, CANCERLIT, CINAHL, Embase, Medline, and PSYCHINFO. Researchers known to be involved in this area of study were contacted and bibliographic references were manually searched. Studies were only included if they were published in the English language; were restricted to participants who had malignancies of the oral cavity; at least 90% of these patients had a histological diagnosis of squamous cell carcinoma; and if they reported data allowing statistical analysis of the duration of patient delay in reporting their cancer. Details of the data extraction process are not given and a qualitative synthesis is presented because of the small number of studies with good methodology and the variability in the factors examined. Of the 148 papers identified as relevant, only eight studies met the inclusion criteria for the review. In these studies, most clinical/tumour factors, socio-demographic variables, and patient health-related behaviours did not influence the duration of patient delay. Healthcare factors and psychosocial factors may play a role but the research in this area is sparse, atheoretical and of poor quality. Patient delay in reporting oral cancer is a problem and yet, at present, the reasons for such delays are poorly understood and under-researched. Systematic, high-quality and theory-driven research in this area is urgently required.

Fluoride prevents caries among adults of all ages.

Abstract: Medline, Embase and the Cochrane Central Register of Controlled Trials were searched. References of each retrieved article were also searched for relevant articles. The US Food and Drug Administration, American Dental Association and manufacturers of topical fluoride products were contacted to identify unpublished trials. For inclusion, the study had to be published in the English language, was of duration 1 year or longer, and examined the association between fluoride and caries in intact human teeth in study populations that included adults. To examine the effectiveness of self- or clinically applied fluoride, only longitudinal studies with random assignment of participants or of split-mouth design were included. For studies examining the effectiveness of water fluoridation, cross-sectional studies were included if their participants lived most of their lives in a fluoridated or a nonfluoridated community. Screening of eligible studies and data extraction were conducted independently and in duplicate. A random-effects model was used to estimate the effect-size of fluoride (absolute difference in annual caries increment or relative risk ratio) for all adults aged 20+ years and for adults aged over 40 years. Root caries increment was also estimated for adults aged over 40 years. Twenty studies involving 13 551 participants were included in the final body of evidence. Eleven studies examined the effectiveness of self- or clinically applied fluoride. Of these studies, 10 were randomised controlled trials, and one was a controlled trial (split-mouth) that did not specify whether the treatment had been randomly assigned. Nine studies examined the effectiveness of water fluoridation; all were cross-sectioned studies except one which was a prospective cohort trial. Of the studies published after or during 1980, any fluoride (self- and clinically applied or water fluoridation) annually averted 0.29 [95% confidence intervals (CI), 0.16–0.42] carious coronal and 0.22 (95% CI, 0.08–0.37) carious root surfaces. The prevented fraction for water fluoridation was 27.2% (95% CI, 19.4–34.3%). These findings suggest that fluoride is effective in preventing caries in adults of all ages.

Calcium hydroxide has limited effectiveness in eliminating bacteria from human root canal.

Abstract: Searches of Cochrane Central Register of Controlled Trials (CENTRAL), Medline, Embase, six thesis databases (Networked Digital Library of Theses and Dissertations, Proquest Digital Dissertations, OAIster, Index to Theses, Australian Digital Thesis program and Dissertation.com) and one conference report database (BIOSIS Previews) were undertaken. There were no language restrictions. Studies were included in which participants had a noncontributory medical history, presented with mature teeth and radiographic evidence of periapical bone loss (as an indication of pre-operative canal infection), whose selected root canals had not previously received any endodontic treatment, and who had undergone nonsurgical root canal treatment during the study in which calcium hydroxide had also been used to seal in the canals. In addition, it was required that microbiological sampling had been undertaken during the course of treatment, before canal preparation, after canal preparation and after canal medication. Aerobic and anaerobic culturing techniques were performed on all samples. The treatment outcomes were stated in terms of positive and negative canal cultures. All data were extracted in the same manner using a standardised data extraction sheet. Between-study heterogeneity was assessed using the standard chi-squared test or Q-statistic. The principal measure of treatment effect (antibacterial efficacy) was risk difference, which is normally defined as the risk in the experimental group minus risk in the control group. For the purpose of this study, it is given as the difference in the proportion of bacteria-positive cultures pre- and post-medication. Out of the eight studies (257 cases) included, one study used a small control group (in which canals were left empty, and no intracanal medicament was used between appointments). The other seven studies simply compared the frequency of positive cultures before and after calcium hydroxide medication. Six studies demonstrated a statistically significant difference between pre- and postmedicated canals, whereas two did not. There was considerable heterogeneity among studies. The pooled risk difference was 21% (95% confidence intervals, 6–47%. The difference in the proportion of cases positive for bacteria before and after treatment was not statistically significant (P = 0.12). Based on the current best available evidence, calcium hydroxide has limited effectiveness in eliminating bacteria from human root canals, when assessed by culture techniques. The quest for better antibacterial protocols and sampling techniques must continue to ensure that bacteria can be reliably eradicated prior to obturation.

How to increase response rates to postal questionnaires

Abstract: Fourteen electronic databases were searched, namely Cochrane Controlled Trials Register, CINAHL (Cumulative Index to Nursing & Allied Health Literature), ERIC (Education Resources Information Center) PsycLit, Dissertation Abstracts, Medline, Embase, Social Science Citation Index, Science Citation Index, Social Psychological Educational Criminological Trials Register, EconLit, Sociological Abstracts, Index to Scientific and Technical Proceedings, and National Research Register. Literature reviews and meta-analyses were inspected for eligible trials and two journals (Public Opinion Quarterly and American Journal of Epidemiology) were searched by hand. Studies included were randomised controlled trials of methods to increase response rates to postal questionnaires. Data describing trial participants, intervention, number of individuals randomised to intervention and comparison groups, and allocation concealment was extracted. For each strategy, pooled odds ratios and 95% confidence intervals in a random-effects model were estimated. Evidence for selection bias was assessed using Egger's weighted regression method, Begg's rank correlation test and funnel plots. Heterogeneity in trial odds ratios was assessed using a chi-square test at a 5% significance level and the degree of inconsistency between trial results was quantified using the I2 statistic (The I2 statistic measures the proportion of the variation across studies that is because of heterogeneity. It is calculated by dividing the heterogeneity chi-square minus the number of degrees of freedom by the heterogeneity chi-square, and then multiplying by 100.). From 372 eligible trials that were included, 98 different ways of increasing response rates to postal questionnaires were evaluated. For 62 of these strategies, the combined trials included over 1000 participants. There was substantial heterogeneity in the trial results from half of the strategies. Strategies found to response are shown in table 1, while three strategies were found to decrease response, questionnaire included questions of a sensitive nature (odds ratio 0.94, 95% CI 0.88–1.00; heterogeneity P =0.51; I2 0%), questionnaires began with the most general questions (odds ratio 0.80, 95% CI 0.67–0.96; heterogeneity Not calculated), Participants were offered the opportunity to opt out of the study (odds ratio 0.76, 95% CI 0.65–0.89; heterogeneity P =0.46, I2 0%). Health researchers using postal questionnaires can increase response rates using the strategies shown to be effective in this systematic review.

Which type of post and core system should you use

Abstract: Articles were sourced using the Cochrane Central Register of Controlled Trials (CENTRAL), Medline, Scopus (abstract and citation database; www.scopus.com ), Embase and the reference lists of articles and dental conference proceedings. Researchers in the field and manufacturers were also contacted. Randomised controlled clinical trials (RCT) or quasi-RCT were selected if they compared failures in endodontically-treated permanent teeth with different types of post. Two review authors independently assessed the quality of trials and extracted data. Study authors were contacted for additional information. Two trials involving 317 participants were included, but only one of them (which had 200 participants) compared metal with nonmetal posts. The other answered the secondary objective. The risk of failure was greater with metal-cast posts (nine out of 98 metal posts failed) than with carbon fibre posts [using which, none out of 97 failed; risk ratio (RR), 0.05; 95% confidence interval (CI), 0.00–0.90] but the study was at high risk of bias. Thus, even though fewer failures occurred when using nonmetal posts, the evidence is unreliable. This review could not specify which type of post and core system should be used when two or three dentine walls remain. More RCT are needed to confirm whether fibre-reinforced post and core systems are superior, and to clarify the influence of the remaining tooth structure on the treatment outcome using different post and core systems. Well-defined inclusion criteria focusing on the number of dentine walls (two or three) should be used.

Paracetamol is an effective drug to use for pain following oral surgery

Abstract: DATA SOURCE Studies were identified using the Cochrane trials registers of the Oral Health Group and of the Pain, Palliative and Supportive Care Group, along with the Cochrane Central Register of Controlled Trials, Medline, Embase and the Current Controlled Trials Register. Handsearching included several dental journals as well as the bibliographies of relevant clinical trials and review articles for studies outside the journals searched by hand. Authors of the randomised controlled trials (RCT) identified and manufacturers of analgesic pharmaceuticals were contacted in an attempt to identify unpublished or ongoing RCT. No language restriction was applied. STUDY SELECTION Randomised, parallel-group, placebo-controlled, double-blind clinical trials of paracetamol (acetaminophen) for acute pain following third molar surgery were included. DATA EXTRACTION AND SYNTHESIS All trials identified were scanned independently and in duplicate by two review authors. Any disagreements were resolved by discussion or, if necessary, a third review author was consulted. The proportion of patients who recorded at least 50% pain relief was calculated for both paracetamol and placebo. The number of patients experiencing adverse events, and/ or the total number of adverse events reported were analysed. RESULTS Twenty-one trials met the inclusion criteria. A total of 2048 people were initially enrolled in the trials (1148 took paracetamol and 892 the placebo) and of these 1968 (96%) were included in the meta-analysis (1133 took paracetamol, and 835 the placebo). Paracetamol provided a statistically significant benefit when compared with placebo for pain relief and for pain intensity at both 4 and 6 h. Most studies were found to have moderate risk of bias, with poorly reported allocation concealment being the main problem. The risk ratio for pain relief at 4 h was 2.85 (95% confidence interval, 1.89-4.29), and at 6 h was 3.32 (95% confidence interval, 1.88-5.87). A statistically significant benefit was also found between doses of <1000 mg and of 1000 mg, the higher dose giving greater benefit for pain relief and intensity at both timepoints. There was no statistically significant difference between the number of patients who reported adverse events: this was 19% in the paracetamol group and 16% in the placebo group. CONCLUSIONS Paracetamol is an effective drug to use for postoperative pain following oral surgery, and the reporting of adverse events shows it to be a safe drug: the number-needed-to-treat (NNT) to benefit is three for 1000 mg of paracetamol at 6 h and the NNT to harm is 33. It is most effective at a 1000 mg dose, and can be taken at 6-hourly intervals without compromising safety. It could be considered more readily by dentist and patients both as a first-choice analgesic, or to be taken alternately with other analgesics such as nonsteroidal anti-inflammatory drugs.

ART for treating root caries in older people.

Abstract: This was pseudo-randomised controlled trial. Root caries lesions were prepared either using the atraumatic restorative technique (ART), using only hand instruments then restoration with a high-strength chemically cured glass-ionomer material (Ketac Molar; 3M Espe, Seefeld, Germany), or conventionally, using dental burs and restoration with a resin-modified glass-ionomer material. (Fuji II LC, GC Corporation, Tokyo, Japan). The presence and status of the restoration, and the need for replacement or repair, were assessed. Sound restorations or restorations with only a marginal defect or wear of <0.5 mm (measured by the ball tip of a CPI periodontal probe) were classified as having survived. The modified US Public Health Service (USPHS) criteria for evaluation of restorative materials were also used to assess the status of the restorations with respect to retention, marginal integrity, marginal discoloration, recurrent caries, anatomical form and surface texture. In total, 162 restorations, comprising 78 ART and 84 conventional, were placed in 103 elderly people (72 women and 31 men) who had a mean age of 78.6 years. The vast majority received either one or two root restorations. Only three of the restorations involved multiple surfaces. After 12 months, 59 ART and 63 conventional restorations in 77 participants were examined. The main results at 12 months are shown in the Table 1. There were no statistical differences between the two types of restorations for each of the USPHS criteria or for 12 month cumulative survival rates (ART, 87.0%; conventional treatment, 91.7%). In elderly people living in care homes, the 12-month survival rate of glass-ionomer restorations placed on root surfaces using the ART was high and comparable with conventional restorations.

Pre-operative chlorhexidine mouth rinses reduce the incidence of dry socket.

Abstract: DATA SOURCES: Medline and the Cochrane library databases were searched and additional studies located by scrutinising publications obtained. STUDY SELECTION: Studies included in analysis were randomised controlled trails (RCT) about prevention of alveolar osteitis (AO) that were written in English, French, German or any of the Nordic languages (Danish, Finnish, Icelandic, Norwegian, Swedish). Duplicate publications, those with flawed data and RCT that generally addressed postoperative complications were excluded. DATA EXTRACTION AND SYNTHESIS: The RCT were quality assessed using the Jadad scale and then categorised and tabulated, according to the main test interventions, to the following domains: antibiotics trials; chlorhexidine trials; trials of PEPH (an antifibrinolytic-active propylic ester of p-hydrobenzoic acid); and other trials including factorial trials (combined interventions) and factorial test groups of RCT belonging to any of the aforementioned domains. RESULTS: A total of 90 publications were identified, from which 32 RCT were included, from 12 different countries, covering the time period 1971-2005. An adequate method of random allocation was reported in 47% of the RCT. Eight different RCT assessed different antibiotic regimens. Tetracycline trials revealed the greatest preventive effects on AO, with absolute risk reductions (ARR) ranging from 12-31% and numbers needed to treat (NNT) ranging from three to eight treated individuals. The effect of chlorhexidine rinses for prevention of AO was studied in five RCT with ARR ranging from 3-25% (NNT, four to 36 treatments). Overall, evidence about chlorhexidine rinses on the prevention of AO was inconclusive, but the available data indicate that 0.12% chlorhexidine rinsing pre-operatively and 7 days postoperatively reduces the frequency of AO following surgical removal of lower third molars. Similarly, evidence for the effectiveness of the antifibrinolytic agent PEPH (considered in three trials) was inconclusive, as was that for the other 18 trials agents. CONCLUSIONS: Local treatment with tetracycline, and also 0.12% chlorhexidine rinsing pre-operatively and 7 days postoperatively, seem to have significant and clinically relevant preventive effect on AO following surgical removal of lower third molars.

Little evidence to support the use of editorial peer review to ensure quality of published research.

Abstract: Studies were identified using the following sources: CINAHL (Cumulative Index to nursing and Allied Health Literature), Cochrane Methodology Register, Dissertation Abstracts, Embase, Evidence-based Medicine Reviews, American College of Physicians Journal Club, Medline, PsycINFO and PubMed. Prospective or retrospective comparative studies were included that had two or more comparison groups, generated by random or other appropriate methods, and that reported original research, regardless of publication status. Because of the variety of study designs, unit of randomisation and outcome measures, a descriptive review was carried out. Twenty-eight studies were included. There was no clear-cut evidence of effect of the well-researched practice of reviewer and/ or author concealment on the outcome of the quality assessment process (nine studies). Checklists and other standardisation media have some evidence to support their use (two studies). There is no evidence that referees’ training has any effect on the quality of the outcome (one study). Different methods of communicating with reviewers and means of dissemination do not appear to have an effect on quality (three studies). On the basis of one study, little can be said about the ability of the peer-review process to detect bias against unconventional drugs. Validity of peer review was tested by only one small study in a specialist area. Editorial peer review appears to make papers more readable and improve the general quality of reporting (two studies), but the evidence for this has very limited generalisability. At present, little empirical evidence is available to support the use of editorial peer review as a mechanism to ensure quality of biomedical research. The methodological problems in studying peer review are many and complex. At present, the absence of evidence on efficacy and effectiveness cannot be interpreted as evidence of their absence. A large, well-funded programme of research on the effects of editorial peer review should be launched urgently.

The fractured edentulous atrophic mandible--open or closed treatment?

Abstract: Data sources The Cochrane Oral Health Group Trials Register, Cochrane Central Register of Controlled Trials, Medline and Embase were used for searches. The Internet was searched for potentially relevant meta-analyses and non-Cochrane systematic reviews, ongoing clinical trials and published dissertations. Reference lists of identified studies were cross-checked for any potentially relevant clinical trials. There were no language restrictions. Study selection Studies were selected if they were randomised controlled trials involving people over 55 years of age with fractures in the symphysis, parasymphysis, body, angle, ramus, condyle, and coronoid process of atrophic edentulous mandibles in which the fracture was a result of trauma, implant insertion or due to pathological fracture. Any studies that compared methods of management (open or closed reduction or fixation) were selected. Data extraction and synthesis Screening of eligible studies was conducted in duplicate and independently by two review authors. It was intended to express results as random-effects models using mean differences for continuous outcomes and risk ratios for dichotomous outcomes with 95% confidence intervals. Heterogeneity was to be investigated including both clinical and methodological factors. Results No eligible randomised controlled trials were identified. Conclusions This review illustrates that there is currently inadequate evidence to support the effectiveness of any single approach, either open or closed, in the management of fractured atrophic edentulous mandibles and that, until high-level evidence is available, treatment decisions should continue to be based on clinician's prior experience. This absence of evidence may in part reflect a certain lack of clarity and the apparent diversity and lack of reliability in some of the traditional and normative predictors of successful outcomes.

Psychological approaches may improve oral hygiene behaviour.

Abstract: Data sources The Cochrane Oral Health Group's Trials Register, Cochrane Central Register of Controlled Trials, Medline, Embase, Psychinfo, Ingenta and Cumulative Index to Nursing and Allied Health Literature were searched, along with the reference lists from relevant articles. The authors of eligible trials were contacted to identify further studies and obtain additional information. Four journals were searched by hand (Journal of Health Psychology, Psychology and Health, Psychology Health and Medicine, Health Psychology - Update). No language restriction was applied. Study selection Randomised controlled trials were selected that tested the effectiveness of interventions based on psychological models, comparing them with educational, attention or no active intervention controls, to improve adherence to oral hygiene in adults with either gingivitis or periodontitis. Only trials with at least 3 weeks' followup were included. Interventions aimed at encouraging smoking cessation were not included. Data extraction and synthesis Titles and abstracts of studies that were potentially relevant to the review were independently screened by two review authors. Those that were clearly ineligible were rejected. For the remaining studies, the full paper was reviewed by two review authors and, where necessary, further information was sought from the author to verify eligibility. The quality of included studies was assessed using standard criteria. Results Four studies (of 344 participants) were found in which a psychological model or theory had been explicitly used as the basis for the design of the intervention. The overall quality of trials was low. Because of the heterogeneity of studies, both in terms of outcome measures and psychological models adopted, a meta-analysis was not possible. The four studies adopted four different theoretical frameworks, although there was some overlap in that three of the studies incorporated elements of Operant and Classical Conditioning. Psychological interventions resulted in improved plaque scores compared with no-intervention groups, and in one study compared with an attention control group. One study found decreased gingival bleeding in the active intervention group but no change in pocket depth or attachment loss after 4 months. Psychological interventions were associated with improved self-reported brushing and flossing in both the studies that assessed these behaviours. Only one study explored the impact of psychological interventions on beliefs and attitudes: the psychological intervention, when compared with educational and no-intervention controls, showed improved self-efficacy beliefs in relation to flossing, but no effect on dental knowledge or self-efficacy beliefs in relation to tooth brushing. Conclusions There is some evidence from low-quality studies that psychological approaches to behaviour management, such as the use of reinforcement, goal setting and the provision of feedback, can improve oral hygiene and oral hygiene-related behaviours. The design of the interventions was weak and limited, however, and ignored key aspects of the theories. All the studies reported here also relied upon the provision of guidance by personnel other than the practitioner. There is no evidence that the use of such an approach by the practitioner with his or her patients would be beneficial. Thus, there is a need for greater methodological rigour in the design of trials in this area.

Behaviour change guidance. National Institute for Health and Clinical Excellence.

Abstract: This guidance was produced by the UK National Institute for Health and Clinical Excellence (NICE), in response to a request from the Department of Health, to produce public health guidance on the most appropriate generic and specific interventions to support attitude and behaviour change at population and community levels. This guidance was developed using the NICE public health programme process. Details of this process can be accessed at the NICE website ( www.nice.org.uk/phmethods ). With all NICE guidelines, a check for new evidence is made at 2 and 4 years after initial publication to decide whether all or part of the guidance should be updated. If important new evidence is published at other times, NICE may decide to update some recommendations at that time. This guidance outlines seven principles, the target audience and recommended actions. Three principles are related to planning of interventions and programmes, three to programme delivery and one to the evaluation of programmes (see Table 1). A number of gaps in the evidence were highlighted, as follows: A series of recommendations relating to future research were also made.

Systemic doxycycline and nonsurgical periodontal treatment in diabetic patients.

Abstract: This was a randomised controlled trial (RCT). Group 1 (30 patients) was given oral-hygiene instruction, scaling and root planing, chlorhexidine rinses twice a day and doxycycline (100 mg/day for 15 days). Group 2 (30 patients) had the same treatment but without doxycycline. Plaque index (PI), probing pocket depth (PPD), clinical attachment levels (CAL) and bleeding on probing (BOP) were recorded. Both groups had a measurable improvement in all periodontal parameters, since PI, BOP, PPD and CAL were reduced. The reduction in PPD of 6 mm and in BOP became statistically significant when doxycycline was used (group 1), however. Although both periodontal treatment regimens are effective in type-1 diabetics, the use of doxycycline as an adjunct provided more significant results when good plaque control was achieved.

Oral health and respiratory diseases. Is there an association between oral health and pneumonia or other respiratory diseases

Abstract: Relevant studies were sourced using Ovid Medline (In-Process and Other Non-Indexed Citations, Daily Update and OLDMedline); Cumulative Index to Nursing and Allied Health Literature; Evidence Based Medicine of Cochrane Central Register of Controlled Trials; Cochrane Database of Systematic Reviews; Database of Abstracts of Reviews of Effects; Embase; Health and Psychosocial Instruments; HealthSTAR; International Pharmaceutical Abstracts; PubMed; and Google Scholar. Randomised controlled clinical trials and longitudinal, cohort, case–control and epidemiological studies were selected. Searches were limited to English language and human studies. Data were extracted independently, evidence tables constructed and a qualitative summary made of the data. Nineteen studies met the inclusion criteria. In five studies, the presence of cariogenic and periodontal pathogens, dental decay, and poor oral hygiene were identified as potential risk factors for pneumonia. A weak association between periodontal disease and chronic obstructive pulmonary disease (COPD) was identified in four poor to fair studies. Ten studies provided evidence that interventions aiming to improve oral health reduced the progression or occurrence of pneumonia. First, there is fair evidence (II-2, grade B recommendation) of an association of pneumonia with oral health [odds ratio (OR), 1.2–9.6 depending on oral health indicators]. Second, there is poor evidence of a weak association (OR<2.0) between COPD and oral health (II-2/3, grade C recommendation). Third, there is good evidence (I, grade A recommendation) that improved oral hygiene and frequent professional oral healthcare reduces the progression or occurrence of respiratory diseases in high-risk elderly adults living in nursing homes and especially those in intensive care units (number needed to treat, 2–16; relative risk reduction, 34–83%).

Periodontal treatment associated with improved glycaemic control in type 2 diabetic patients.

Abstract: Periodontal treatment associated with improved glycaemic control in type 2 diabetic patients

Torn labial frenum in isolation not pathognomonic of physical abuse.

Abstract: Data source Searches were made for studies using Applied Social Sciences Index and Abstracts, Caredata (the social work and social care knowledge base), Child Data (the National Children's Bureau Database), the Cumulative Index to Nursing and Allied Health, Embase, Medline, the System for Information on Grey Literature in Europe, the TRIP database (www.tripdatabase.com), Sciences Citation Index, and ISI Proceedings (covers conference papers in all scientific and technical fields). Authors were contacted where necessary. Study selection All studies of children 0-18 years with intra-oral injuries because of physical child abuse, and torn labial frena of any aetiology, in live and fatal cases were included. Review articles, expert opinion or guidelines that did not include primary evidence, studies with mixed adult and child data where the children's data could not be extracted, studies that addressed complications or management of abusive injuries, intra-oral injuries because of sexual abuse, thermal injuries or dental neglect were excluded. Data extraction and synthesis Studies were reviewed by the Welsh Child Protection Systematic Review Group. Standardised data extraction and appraisal forms were used and a qualitative synthesis undertaken. Results Nineteen out of 154 studies reviewed were included, representing 591 children. There were no comparative studies of accidental and abusive torn labial frenum to enable a probability of abuse to be determined. Nine studies documented abusive torn labial frena in 27 children, of whom 22 were younger than 5 years old and 24 had been fatally abused. Only a direct blow to the face was substantiated as a mechanism of injury. Two studies noted accidentally torn labial frena, both from intubation. Abusive intra-oral injuries were widely distributed to the lips, gums, tongue and palate and included fractures, intrusion and extraction of the dentition, bites and contusions. Conclusions Current literature does not support the diagnosis of abuse based on a torn labial frenum in isolation. The intra-oral hard and soft tissue should be examined in all suspected abuse cases, and a dental opinion sought where abnormalities are found.ome of the traditional and normative predictors of successful outcomes.

Viewing positive images of dentistry reduces anticipatory anxiety in children

Abstract: Top of pageAbstract Design This was a randomised controlled trial (RCT). Intervention Participants were randomised to viewing positive images of dentistry and dental or dentally neutral photographs for 2 min in the waiting area prior to their appointment. Outcome measure Anticipatory anxiety assessed by the Venham Picture Test. Results A significant difference in anticipatory dental anxiety was found between the two groups (median-positive images, 0; median-neutral images, 3; P 0.05) and there was no significant difference between male and female participants in their level of anticipatory anxiety (median for males, 0.5; median for females, 1; P>0.05). Conclusions Viewing positive images of dentistry and dentists results in short-term reductions in anticipatory anxiety in children.

Long-term stability after orthodontic treatment remains inconclusive

Abstract: Data sources PubMed and Cochrane Library electronic databases were searched from 1966 to January 2005. Reference lists of the relevant studies were searched by hand. Study selection For inclusion, articles had to satisfy the following criteria: have a follow-up period of at least 5 years post-retention; report on randomised clinical trials (RCT), prospective or retrospective clinical controlled studies or on cohort studies; and investigate orthodontic treatment including fixed or removable appliances, selective grinding or extractions. Data extraction and synthesis Screening of eligible studies, data extraction and assessment of methodological quality was conducted independently and in duplicate. The level of evidence of the included studies was graded as high, moderate or low according to predetermined criteria. Results The search strategy resulted in 1004 abstracts or full-text articles, of which 38 met the inclusion criteria. Treatment of crowding resulted in successful dental alignment but the mandibular arch length and intercanine width gradually decreased, and crowding of the lower anterior teeth reoccurred post-retention. This condition was unpredictable at the individual level. Treatment of Angle class-II division-1 malocclusion with a Herbst appliance normalised the occlusion. Relapse occurred but could not be predicted at the individual level. The scientific evidence was insufficient to draw conclusions about treatment of cross-bite, angle class III, open-bite and various other malocclusions, or about long-term patient satisfaction. Conclusions Despite a large number of studies on long-term stability after orthodontic treatment, this systematic review shows that evidence-based conclusions are few. This is mostly because of inherent problems with retrospective and inferior study design. There is a great need for well-designed prospective studies with untreated control groups; sufficient sample sizes; and sample selection according to type of malocclusion, age and growth pattern.