Showing papers in "Evidence-based Dentistry in 2008"

A systematic review of the efficacy and safety of fluoridation

Abstract: The systematic review was commissioned by the Australian National Health and Medical Research Council (NHMRC) to evaluate the scientific literature relating to the health effects of fluoride and fluoridation. The systematic review's research questions relate to the caries-reducing benefits and associated potential health risks of providing fluoride systemically (via addition to water, milk and salt) and the use of topical fluoride agents, such as toothpaste, gel, varnish and mouthrinse. Although the review summarises the recent evidence, it does not constitute health policy or clinical practice recommendations. A literature search was undertaken using the Medline and Embase databases (via www.embase.com ). In addition, the Cochrane Systematic Review and Clinical Trial databases were searched to help identify additional systematic reviews and original studies. Because of the availability of recent systematic reviews, searches were limited to publications from 1996 onwards . The search was conducted in December 2006 and limited to English-language publications. Based on types of intervention (individual or population) and the outcomes assessed (efficacy or safety), the hierarchy of study types considered most relevant for answering each of the clinical questions defined in this review was chosen (Table 1). The levels of evidence used by NHMRC for intervention and aetiological studies are summarised in Table 2. Screening of eligible studies was conducted by three reviewers. Data were extracted for all of the included systematic reviews and individual studies using standardised data-extraction forms. This included information about the study design, NHMRC level of evidence, population, intervention, comparator, outcome definitions and results. Information relating to potential biases and study quality were also extracted. Where appropriate, study results were pooled using standard meta-analysis techniques. In total, 5418 nonduplicate citations were identified. After applying the inclusion and exclusion criteria, 408 citations were considered potentially eligible for inclusion in the review. After the review of the full papers of potentially eligible articles, 77 citations were included in the review. The summary of findings was presented in the context of the research questions (Table 3). Fluoridation of drinking water remains the most effective and socially equitable means of achieving community-wide exposure to the caries prevention effects of fluoride. It is recommended (see also www.nhmrc.gov.au/news/media/rel07/_files/fluoride_flyer.pdf ) that water be fluoridated in the target range of 0.6–1.1 mg/l, depending on the climate, to balance reduction of dental caries and occurrence of dental fluorosis.n particular with reference to care in hospital for those following stroke.

Prophylaxis against infective endocarditis.

Abstract: Methods The guideline was developed by a guideline development group consisting of 12 members and a National Institute for Health and Clinical Excellence (NICE) Short Clinical Guidelines Technical Team using methods described in the NICE guidelines manual (available from www. nice.org.uk/guidelinesmanual). Review and updating Review and updating will take place in line with procedures outlined in the NICE guidelines manual. Recommendations Recommendations were as follows: 1. Healthcare professionals should regard people with the following cardiac conditions as being at risk of developing infective endocarditis (IE): • acquired valvular heart disease with stenosis or regurgitation • valve replacement • structural congenital heart disease, including surgically corrected or palliated structural conditions, but excluding isolated atrial septal defect, fully repaired ventricular septal defect or fully repaired patent ductus arteriosus, and closure devices that are judged to be endothelialised • previous IE • hypertrophic cardiomyopathy 2. Healthcare professionals should offer people at risk of IE clear and consistent information about prevention, including: • the benefits and risks of antibiotic prophylaxis, and an explanation of why antibiotic prophylaxis is no longer routinely recommended • the importance of maintaining good oral health • symptoms that may indicate IE and when to seek expert advice • the risks of undergoing invasive procedures, including nonmedical procedures such as body piercing or tattooing 3. Antibiotic prophylaxis against IE is not recommended: • for people undergoing dental procedures • for people undergoing nondental procedures at the following sites: upper and lower gastrointestinal tract; genitourinary tract (includes urological, gynaecological and obstetric procedures, and childbirth); and upper and lower respiratory tract (includes ear, nose and throat procedures and bronchoscopy) 4. Chlorhexidine mouthwash should not be offered as prophylaxis against IE to people at risk of IE when they undergo dental procedures. 5. Any episodes of infection in people at risk of IE should be investigated and treated promptly to reduce the risk of endocarditis developing. 6. If a person at risk of IE is receiving antimicrobial therapy because they are undergoing a gastrointestinal or genitourinary procedure at a site where there is a suspected infection, the person should receive an antibiotic whose spectrum covers organisms that cause IE. Research recommendations IE is a rare condition and UK research in this area would be facilitated by the availability of a national register of IE cases that could offer data into the ‘case’ arm of proposed case– control studies. Two specific areas of required research were highlighted. First, the risk of developing IE in people who have acquired valvular disease and structural congenital heart disease should be investigated using a population-based cohort study design to allow direct comparison between groups and estimation of both relative and absolute risk. Second, the frequency and level of bacteraemia caused by nonoral daily activities (for example, urination or defecation) requires research to determine quantitatively the frequency and level of bacteraemia.

Handsearching still a valuable element of the systematic review

Abstract: Data sources The Cochrane Methodology Register, Medline, Embase, AMED, Biosis, Cinahl, LISA, and Psycinfo were consulted along with researchers who may have carried out relevant studies. Study selection Studies were considered eligible if they compared searching by hand with searching one or more electronic databases to identify reports of randomised trials. Data extraction and synthesis The main outcome measure was the number of reports of randomised trials identified from searches made by hand compared with electronic searching. Data were extracted regarding the electronic database searched, the complexity of electronic search strategy used, the characteristics of the journal reports identified, and the type of trial report identified. Results Thirty-four studies were included. Handsearching identified between 92 and 100% of the total number of reports of randomised trials found in the various comparisons in this review. Searching Medline retrieved 55%, Embase 49% and Psycinfo 67%. The retrieval rate of the electronic database varied depending on the complexity of the search. The Cochrane highly sensitive search strategy (HSSS) identified 80% of the total number of reports of randomised trials found; searches categorised as 'complex' (including the Cochrane HSSS) found 65% and 'simple' searches found 42%. The retrieval rate for an electronic search was higher when the search was restricted to English-language journals, at 62% versus 39% for journals published in languages other than English. When the search was restricted to full reports of randomised trials, the retrieval rate for an electronic search improved: a complex search strategy retrieved 82% of the total number of such reports of randomised trials. Conclusions Hand searching is still valuable in identifying randomised trials for inclusion in systematic reviews of healthcare, particularly trials reported as abstracts or letters, those published in languages other than English, along with all reports published in journals not indexed in electronic databases. Where time and resources are limited, however, searching an electronic database using a complex search (or the Cochrane HSSS) will identify the majority of trials published as full reports in English language journals, provided, of course, that the relevant journals have been indexed in the database.

Periodontal disease and adverse pregnancy outcomes.

Abstract: DESIGN This was a prospective cohort study. COHORT SELECTION: The initial sample comprised 1404 pregnant women seeking prenatal care at the University Hospital of Lleida (Spain) between March 2003 and January 2005. DATA COLLECTION AND ANALYSIS Periodontal data [full-mouth data, pocket probing depths (PPD) and clinical attachment levels (CAL) and bleeding on probing], pregnancy outcome variables and information on other factors that may influence adverse pregnancy outcomes were collected. Data were analysed using a logistic regression model. RESULTS The incidence of preterm birth (PB) and low birthweight (LBW) was 6.6% and 6.0%, respectively. The incidence of preterm LBW (PLBW) was 3.3%. PB was related to mother's age, systemic disease, onset of prenatal care, previous PB, complications of pregnancy, type of delivery, the presence of untreated caries and the presence of periodontitis (odds ratio, 1.77; 95% confidence interval, 1.08-2.88). LBW was related to the mother's smoking habits, ethnicity, systemic diseases, previous LBW babies, complications of pregnancy and type of delivery. PLBW was related to the mother's age, onset of prenatal care, systemic diseases, previous LBW babies, complications of pregnancy and type of delivery. CONCLUSIONS The factors involved in many cases of adverse pregnancy outcomes have still not being identified, although systemic infections may play a role. This study found a modest association between periodontitis and PB. Further research is required to establish whether periodontitis is a risk factor for PB and/ or LBW.

How common is oral lichen planus

Abstract: Medline and ISI Web of Science were searched, along with references of identified papers. Studies reporting the prevalence or incidence of oral lichen planus (OLP) were included. Papers were examined for five criteria: use of a clinic- or population-based study; adequate demographic description (by sex and age group) of the population; adequate demographic description of the sample (if the population was sampled); adequate demographic description of the OLP cases identified; and histological confirmation of the clinical diagnosis. Forty-five relevant papers were identified, of which 21 were clinic-based and 24 were population studies. All but one of the population studies was deficient. The one remaining study, while having some defects, was probably of sufficient quality to make its findings useful. An overall age-standardised prevalence of 1.27% (0.96% in men and 1.57% in women) can be calculated from this study. Only one of the studies identified for the review contained sufficient detail about its methods and of its findings to enable an estimate of population prevalence to be calculated. This did not distinguish between OLP and lichenoid reactions, however. Further, well-designed, studies with using standardised methods and criteria, are required in a number of different populations.

Studies suggest an association between maternal periodontal disease and pre-eclampsia.

Abstract: In this systematic review, several types of infections are identified and investigated: urinary tract infection, periodontal disease, Chlamydia pneumoniae infection, HIV infection, malaria and other persistent bacterial and viral infections. Separate analyses were conducted for each of them. This summary review will only focus on the link between pre-eclampsia and periodontitis, which was just a part of the original systematic review. MEDLINE, EMBASE, POPLINE, CINAHL, LILACS (all from inception to June 30, 2007), proceedings of international meetings on pre-eclampsia, bibliography of the retrieved articles, reviews, chapters in standard textbooks on hypertension in pregnancy, and contact with investigators involved in the field were used to identify relevant studies. No language restrictions were imposed. Cohort, case-control or cross-sectional studies with original data that evaluated the association between maternal periodontal disease and pre-eclampsia were included. Cases were defined as women suffering from hypertension plus proteinuria, after 20 weeks' gestation. Data were extracted from each study according to design, geographic location, sample size, gestational age when periodontal disease was diagnosed, definition and severity of pre-eclampsia, confounding factors controlled for, temporality of the association, and report of dose-response gradient. Studies included in the systematic review were also included in the meta-analysis if they reported Odds Ratio (OR) or Relative Risk (RR) estimates with their 95% Confidence Intervals (CIs), or provided the information necessary to calculate them. Results from different reports were combined to produce a pooled OR according to the Mantel-Haenszel method, using both fixed- and random-effects models. Heterogeneity was quantified with I2 statistics. Studies were also quality assessed. Seven case-control studies and 2 cohort studies evaluated the association between periodontal disease and pre-eclampsia. Six studies, representing a total of 3420 women (493 pre-eclamptic and 2927 non-pre-eclamptic control women) were pooled for meta-analysis. Women with evidence of periodontal disease during pregnancy had a 1.76 fold higher risk of pre-eclampsia compared with women without periodontal disease (OR, 1.76, 95% CI: 1.43–2.18). Periodontal disease during pregnancy is associated with an increased risk of pre-eclampsia. More studies are required to verify this as well as to explore whether or not such relationship is causal and, if so, the mechanisms involved.

The effect of a mouthrinse containing essential oils on dental plaque and gingivitis.

Abstract: PubMed and the Cochrane Central Register of Controlled Trials were searched up to December 2006 were searched. Only studies published in English were included. Randomised controlled clinical trials, controlled clinical trials and uncontrolled longitudinal clinical trials were included in the initial search. Studies with a minimum duration of 6 months, healthy subjects ≥18 and gingivitis without severe periodontal disease were included. The effects of plaque and gingivitis were considered the primary outcomes with staining of teeth a secondary outcome. Studies were screened and data extracted independently by two reviewers. It is unclear whether or not this process was duplicated. Disagreements were resolved by discussion. Heterogeneity of the studies was assessed. Data was pooled for gingivitis and plaque and a weighted means meta-analysis using a random effects model was carried out. Eleven studies (all randomised controlled trials) met the inclusion criteria. All were of six months duration except one of nine months. There was no meta-analysis between baseline and end trial as the standard deviation could not be calculated. Three studies were not included in the meta-analysis. Meta-analysis of staining was not carried out. There was significant reduction in gingivitis with EO mouthrinses compared to control groups regardless of the measurement index used (Weighted Means Difference (WMD) -0.32 95% Confidence Interval (CI) [-0.46 to -0.19], P< 0.00001; test for heterogeneity: P<0.00001 I2 =96.7%). A significant reduction in interproximal gingivitis was also noted for EO mouthrinses compared to control (WMD -0.29 95% CI [-0.48 to -0.11] P=0.002; test for heterogeneity: p<0.0001 I2=95.8%) and compared to floss (WMD -0.05 95% CI [-0.20 to -0.09] P=0.48; test for heterogeneity: P=0.0001 I2=99.7%). Similar results were seen for the effects on plaque with a decrease in total plaque in favour of EO mouthrinse (WMD -0.83 95% CI [-1.13 to -.053] P<0.00001; test for heterogeneity: P<0.00001 I2= 96.1%). Significant interproximal plaque reduction, again in favour of EO mouthrinse, was also seen compared to control (WMD -1.02 [-1.44 to -0.60] P<0.00001; test for heterogeneity: P<0.00001 I2=96.1% 95% CI) and compared to floss (WMD -0.75 95% CI [-1.15 to -0.363] P<0.0002; test for heterogeneity: P<0.0002 I2= 93%) When used as an adjunct to unsupervised oral hygiene, the existing evidence supports that essential oil provides an additional benefit with regard to plaque and gingivitis reduction compared to placebo or control.

Fluoride varnish reduces white spot lesions during orthodontic treatment

Abstract: This was a randomised controlled trial (RCT) set in a community dental practice. The test varnish was a commercially available product, Fluor Protector (Ivoclar Vivadent, Schaan, Liechtenstein), containing 0.1% fluoride as difluorosilane in a polyurethane varnish base. The placebo varnish applied had an identical composition but without fluoride. The incidence and prevalence of white spot lesions (WSL) on the upper incisors, cuspids and premolars were recorded, as scored from digital photographs by two independent examiners. In the case of disagreement, cases were re-examined until a consensus was achieved. The incidence of WSL during the treatment period was 7.4% in the fluoride varnish group compared with 25.3% placebo group (P <0.001). The mean progression score was significantly lower in the fluoride varnish group than in the placebo group, (0.8 ± 2.0 vs 2.6 ± 2.8; P <0.001). The absolute risk reduction was 18% and the number-needed-to-treat was calculated to be 5.5 (95% confidence interval, 3.7–10.9). The results strongly suggest that regular topical fluoride varnish applications may reduce the development of WSL adjacent to the bracket base during treatment with fixed appliances.

Breastfeeding and the risk of early childhood caries.

Abstract: Search strategy The databases Medline (1996–2008), Embase (1996–2008) and CINAHL (1982– 2008) were searched using OVID, along with all evidence-based medicine journals within OVID, PubMed and Trip Database (www.tripdatabase.com). The OVID search (see Table 1) used the following search terms: “breastfeeding” or “infant feeding” and “dental caries” or “oral health”. Studies were limited to human subjects and English language and review articles (where possible). The OVID search identified 30 studies of which four were considered relevant. The PubMed and Trip database searches used similar search terms with only the PubMed search identifying an additional study. Details of the papers are summarised in Table 2.

Deep or partial caries removal: which is best?

Abstract: Top of pageAbstract Data sources Searches for studies were made using the databases: Medline, Evidence-based Medicine Reviews, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials and OVID's Database of Abstracts of Reviews of Effects. Study selection Only studies reported in English with human participants were included. Randomised controlled trials (RCT) and relevant observational studies were included. No other inclusion or exclusion criteria are described. Data extraction and synthesis A formal data extraction process is not described and a qualitative description of the included studies is provided. Results Ten articles reporting six studies were included. The results of three RCT, one with a followup period of 10 years, provide evidence supporting the practice of leaving behind infected dentine, the removal of which would risk pulp exposure. A number of other studies show that cariogenic bacteria, once isolated from their source of nutrition by a restoration of sufficient integrity, either remain dormant or die and thus pose no risk to the health of the dentition. Conclusions There is substantial evidence that, for caries management, it is not necessary to remove all vestiges of infected dentin from lesions approaching the pulp.

The effectiveness of occlusal splints for sleep bruxism.

Abstract: Searches were made using the Cochrane Oral Health Group's Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL), Medline, Embase, LILACS (Latin American & Caribbean Health Sciences Literature), Biblioteca Brasileira de Odontologia, and Dissertations, Theses and Abstracts. Hand searches were made of abstracts of particular importance to this review. Additional reports were identified from the reference lists of retrieved reports and from article reviews about treating sleep bruxism. There were no language restrictions. Randomised controlled trials (RCT) or quasi-RCT were chosen that compared splint therapy concurrently with no treatment, other occlusal appliances, or any other intervention in participants who had sleep bruxism. Data extraction was carried out independently and in duplicate. Validity assessment of the included trials was carried out at the same time as data extraction. Discrepancies were discussed and a third review author consulted. The author of the primary study was contacted when necessary. Thirty-two potentially relevant RCT were identified of which five were eventually included. In these, use of an occlusal splint was compared with palatal splint, mandibular advancement device, transcutaneous electric nerve stimulation, and no treatment. There was just one common outcome (arousal index) which was combined in a meta-analysis. No statistically significant difference between the occlusal splint and control groups were found in meta-analysis. There is not enough evidence to state that the occlusal splint is effective for treating sleep bruxism. Indication of its use is questionable with regard to sleep outcomes, but there may be some benefit with regard to tooth wear. This systematic review suggests the need for further investigation in more controlled RCT that pay attention to method of allocation, outcome assessment, large sample size, and sufficient duration of followup. The study design must be parallel in order to eliminate the bias provided by studies of crossover type. A standardisation of the outcomes of the treatment of sleep bruxism should be established in the RCT.

Growing body of evidence on survival rates of implant-supported fixed prostheses.

Abstract: Data sources Medline and manual searches were made of the bibliographies of all full-text articles and related reviews selected from the electronic search and the following journals: American Journal of Dentistry, Australian Dental Journal, British Journal of Oral and Maxillofacial Surgery, Clinical Implant Dentistry and Related Research, Clinical Oral Implants Research, Deutsche Zahnarztliche Zeitschrift, European Journal of Oral Sciences, International Dental Journal, International Journal of Oral and Maxillofacial Implants, International Journal of Periodontics and Restorative Dentistry, International Journal of Prosthodontics, Journal de Parodontologie, Journal of Clinical Periodontology, Journal of Dental Research, Journal of Oral Implantology, Journal of Oral Rehabilitation, Journal of Periodontology, Journal of Prosthetic Dentistry, Quintessence International, Swedish Dental Journal and Schweizerische Monatsschrift Zahnmedizin. Study selection Prospective or retrospective cohort studies were included if they had a mean follow-up of 5 years or more; were reported in the dental literature in the English or German language; patients had been examined clinically at the follow-up visit; and details of the characteristics of the suprastructures were reported. Publications that combined findings for both implant-supported fixed partial dentures and single-tooth crowns were selected if they allowed for extraction of the data for the single-tooth crowns group. Publications based on patient records only or on questionnaires or interviews were excluded. Data extraction and synthesis Failure and complication rates are calculated by dividing the number of events (failures or complications; the numerator) by the total exposure time [single crown (SC) time and/ or implant time; the denominator]. Event rates for SC and/ or implants were calculated by dividing the total number of events by the total SC or implant exposure time in years. The total number of events was considered to be Poisson distributed. To assess heterogeneity of the study-specific event rates, the Spearman goodness-of fit statistics and associated probability value were calculated. Multivariable Poisson regression was used to investigate formally whether event rates varied by crown material (metal-ceramic vs all-ceramic) or crown design (cemented vs screw-retained). Results Twenty-six studies were included in the meta-analysis. Survival of implants supporting SC was 96.8% [95% confidence interval (CI), 95.9-97.6%] after 5 years. The survival rate of SC supported by implants was 94.5% (95% CI, 92.5-95.9%) after 5 years of function. The survival rate of metal-ceramic crowns, 95.4% (95% CI, 93.6-96.7%), was significantly higher (P 0.005) than the survival rate (91.2%; 95% CI, 86.8-94.2%), of all-ceramic crowns. Peri-implantitis and soft tissue complications occurred adjacent to 9.7% of the SC and 6.3% of the implants had bone loss exceeding 2 mm over the 5-year observation period. The cumulative incidence of implant fractures after 5 years was 0.14%. After 5 years, the cumulative incidence of screw or abutment loosening was 12.7%, and was 0.35% for screw or abutment fracture. For suprastructure-related complications, the cumulative incidence of ceramic or veneer fractures was 4.5%. Conclusions An observation period of 5 years allows the conclusion that high survival rates of implants and implant-supported SC can be expected, but biological and, particularly, technical complications are frequent.

Gastro-oesophageal reflux and dental erosion.

Abstract: DATA SOURCES Relevant studies were sourced using Medline and the Cochrane Controlled Trials Register, along with reference lists from identified papers and reviews. STUDY SELECTION Full papers were selected that assessed the prevalence of dental erosion in individuals who had gastro-oesophageal reflux (GERD), or vice versa, which were published in the English language. DATA EXTRACTION AND SYNTHESIS Data extractions was carried out by at least two authors using a standardised data extraction form. Because of a marked variation in outcome measures, qualitative synthesis was carried out. RESULTS Seventeen studies met the selection criteria but they differed greatly in design, population, methods of diagnosing GERD, duration of followup and, consequently, in their findings. The median prevalence of dental erosion in GERD patients was 24%, with a large range (5-48%), and the median prevalence of GERD in dental erosion adults patients was 32.5% (range, 21-83%) and 17% in paediatric patients (range, 14-87%). CONCLUSIONS This systematic review shows that there is a strong association between GERD and dental erosion. The severity of dental erosion seems to be correlated with the presence of GERD symptoms and also, at least in adults, with the severity of proximal oesophageal or oral exposure to an acidic pH. The inspection of the oral cavity in search for dental erosions should become a routine manoeuvre in patients who have GERD.

The Hall technique is an effective treatment option for carious primary molar teeth.

Abstract: This was a general dental practice (GDP)-based, split-mouth, randomised controlled trial (RCT). The Hall technique, where a preformed metal crown (PMC) is cemented with no local anaesthesia, caries removal or tooth preparation, was compared with restoration with the material the GDP would normally choose. The outcomes were recorded as success; minor failure (restoration failure or reversible pulpitis, which could be managed by repair or replacement); or major failure (signs or symptoms of irreversible pulpal damage, such as dental abscess, or tooth broken down and unfeasible to repair or replace the restoration). A total of 128 conventional restorations were placed on 132 control teeth, and 128 PMC on 132 intervention teeth. Eighty-nine per cent of Hall PMC were rated by dentists as causing no apparent discomfort through to merely mild discomfort: for the control restorations this was 78% (not a significant difference). The Hall PMC outperformed the control restorations in terms of the number of major and minor failures (see Table 1). Preference for the Hall technique was recorded at 77% for the children, 83% for carers and 81% for dentists who expressed a preference, which this was significant (Chi square, P<0.0001). The Hall technique was preferred to conventional restorations by the majority of children, carers and dental practitioners. After 2 years, Hall PMC showed more favourable outcomes for pulpal health and restoration longevity than conventional restorations. The Hall technique appears to offer an effective treatment option for carious primary molar teeth.

Do folic acid supplements reduce facial clefts

Abstract: Design This was a national population-based case-control study in Norway. CASE AND CONTROL SELECTION: Cases consisted of all newborn infants born from 1996-2001 who had been referred for surgical treatment of a cleft [either cleft lip with or without cleft palate (377 children) or cleft palate only (196 children)]. Controls (763) were a randomly selected at an average of four per 1000 live births (identified through the medical birth registry of Norway). Data analysis Data were collected using questionnaires. Crude odds ratios (OR) were calculated and adjustments for potential confounders (diet and multivitamins, mother's education, mother's employment during early pregnancy, smoking, alcohol consumption, and year of baby's birth) were made. Results Folic acid supplementation during early pregnancy (400 microg/day) was associated with a reduced risk of isolated cleft lip with or without cleft palate after adjustment for multivitamins, smoking, and other potential confounding factors [adjusted OR, 0.61; 95% confidence interval (CI), 0.39-0.96]. Independent of supplements, diets rich in fruits, vegetables and other high-folate-containing foods reduced the risk somewhat (adjusted OR, 0.75; 95% CI, 0.50-1.11). The lowest risk of cleft lip was among women who ate folate-rich diets who also took folic acid supplements and multivitamins (adjusted OR, 0.36; 95% CI, 0.17-0.77). Folic acid provided no protection against cleft palate alone (adjusted OR, 1.07; 95% CI, 0.56-2.03). Conclusions Folic acid supplements during early pregnancy seem to reduce the risk of isolated cleft lip (with or without cleft palate) by about a third. Other vitamins and dietary factors may provide additional benefit.

Single or multiple visits for endodontic treatment

Abstract: Searches for relevant studies were made using the Cochrane Oral Health Group's Trials Register, CENTRAL, Medline and Embase. The major oral medicine journals were also searched by hand and reference lists of included studies and reviews were checked. Endodontics experts were contacted by e-mail. No language limitations were imposed. Randomised controlled trials (RCT) and quasi-RCT of root canal treatment were included. Surgical endodontic treatment was excluded. The outcomes considered were the number of teeth extracted for endodontic problems; radiological success (absence of any periapical radiolucency) after at least 1 year; postoperative pain; painkiller use; swelling; or sinus track formation. Data were collected using a specific extraction form. The validity of the studies included was assessed on the basis of allocation concealment, blindness of the study, and loss of participants. Data were analysed by calculating risk ratios. When valid and relevant data were collected, a meta-analysis of the data was undertaken. Twelve RCT were included in the review. Four studies had a low risk of bias, four a moderate risk, and another four had a high risk of bias. The frequency of radiological success and immediate postoperative pain were not significantly different between single- and multiple-visit root canal treatments. People who had single-visit treatment reported a higher frequency of painkiller use and swelling, but the results for swelling were not significantly different between the two groups. We found no study that included tooth loss and sinus track formation among its primary outcomes. No difference exists in the effectiveness of root canal treatment, in terms of radiological success, between single- and multiple-visit treatments. Most short- and long-term complications are also similar in terms of frequency, although patients undergoing a single visit may experience a slightly higher frequency of swelling and are significantly more likely to take painkillers.

Possible link between periodontal disease and coronary heart disease.

Abstract: Medline, Cochrane Library, Embase, Cinahl and the reference lists of published articles were used to identify relevant studies. Studies were included if the sample sizes were >80 cases, cases were defined as people with fatal or nonfatal coronary artery disease (CAD); described either self-reported periodontal disease (PD) or that diagnosed by clinical assessment of oral health; and provided relative risks (RR) and odds ratios (OR,) or sufficient information for the calculation of RR or OR. Letters, unpublished articles, animal studies, duplicate reports and those providing association between different markers of CAD or particular pathogens involved in PD were excluded. Data was extracted by two investigators using a standard protocol. Cohort studies, case–control studies and cross-sectional studies were analysed separately using the Comprehensive Meta-Analysis software package (version CM 2.2; Biostat, Englewood, New Jersey, USA). Heterogeneity of the studies was assessed using the Cochrane Q test. As the studies were homogeneous the Mantel-Haenszel fixed-effect model was used to compute common RR and OR. Meta-analysis of the five prospective cohort studies (86 092 patients) found people with PD had a 1.14-fold higher risk of developing coronary heart disease (CHD) than controls [RR, 1.14; 95% confidence interval (CI), 1.07–1.21; P<0.001]. Case–control studies (1423 patients) showed an even greater risk of developing CHD (OR, 2.22; 95% CI, 1.59–3.117; P<0.001). The prevalence of CHD in the cross-sectional studies (17 724 patients) was significantly greater in individuals with PD than in those with no PD (OR, 1.59; 95% CI, 1.33–1.91; P<0.001). Analysing the relationship between number of teeth and incidence of CHD found a 1.24-fold increased risk (95% CI, 1.14–1.36; P<0.0001) of development of CHD in people who had <10 teeth. This study suggests a possible association between PD and CHD. Elevated levels of inflammatory mediators in people who have PD suggest a role in atherothrombogenesis leading to CHD. Well-designed prospective cohort studies, with uniform definitions of PD and CHD, investigating the role of periodontal pathogen-burden on the occurrence of CHD and the management of patients with PD to reduce the future risk of development of CHD, are necessary.

Guidelines for the management of patients who are taking oral anticoagulants and who require dental surgery.

Abstract: Guidelines for the management of patients who are taking oral anticoagulants and who require dental surgery

The TRIP database.

Abstract: The TRIP (Turning Research into Practice) database has an apparently simple goal: to allow health professionals to easily find the highest-quality material available on the Web to help support evidence-based practice.

No difference between failure rates of early and conventionally loaded implants.

Abstract: The Cochrane Oral Health Group's Trials Register, Cochrane Central Register of Controlled Trials, Medline and Embase were searched. Handsearching included several dental journals. Authors of all identified trials, an internet discussion group and 55 dental implant manufacturers were contacted to find unpublished randomised controlled trials (RCT). RCT were selected of root-form osseo-integrated oral implants that had a followup of 6 months–1 year and which compared the same osseo-integrated root-form implants immediately (within 1 week), early (1 week–2 months) and conventionally loaded (after 2 months), giving the following outcome measures: failures, implant failures and marginal bone levels on intra-oral radiographs. Data were independently extracted, in duplicate, by two review authors. Authors were contacted for details of randomisation and withdrawals and a quality assessment was carried out. The Cochrane Oral Health Group's statistical guidelines were followed. Twenty RCT were identified and 11 trials comprising a total of 300 patients were included. Six trials compared immediate versus conventional loading, three early versus conventional loading and two immediate versus early loading. On a patient, rather than per implant basis, there were no statistically significant differences for any of the meta-analyses. It is possible to successfully load dental implants immediately or early after their placement in selected patients, but not all clinicians achieve optimal results when loading the implant immediately. A high degree of primary implant stability (high value of insertion torque) seems to be one of the prerequisites for a successful immediate/ early loading procedure. More well-designed RCT are needed. Priority should be given to trials comparing immediately versus early loaded implants to improve patient satisfaction and decrease treatment time and trials should be reported according to the CONSORT guidelines ( http://www.consort-statement.org/ ).

No good evidence to link toothbrushing trauma to gingival recession

Abstract: Medline, Embase, Web of Knowledge, the Cochrane Central Register of Controlled Trials, Current Contents Connect and the Google Scholar databases were searched. Searches by hand were also made of the Journal of Clinical Periodontology, Journal of Periodontal Research and the Journal of Periodontology. Bibliographies of narrative reviews, conference proceedings and relevant texts known to the authors were also searched. Screening of studies was carried out independently by three reviewers and assessed for quality. Studies of Level III, ie, observational studies without control groups (cross sectional studies, before-and-after studies, case series) or better were included. Studies reported in the English, German, Spanish or Greek language were included. Data were extracted from the full-text articles using a purposely designed data extraction form, and a qualitative summary was carried out. Eighteen studies were included. One abstract from the meeting EuroPerio 5 reported a randomised-controlled clinical trial (RCT; Level I evidence) in which the authors concluded that the toothbrushes significantly reduced recessions on buccal tooth surfaces over the course of 18 months. Of the remaining 17 observational studies, two concluded there was no apparent relationship between toothbrushing frequency and gingival recession. Eight studies reported a positive association between toothbrushing frequency and recession. Other potential risk factors were duration of toothbrushing, brushing force, and frequency of changing the toothbrush, brush (bristle) hardness and toothbrushing technique. None of the observational studies satisfied all the specified criteria for quality appraisal, and a valid appraisal of the quality of the RCT was not possible. The data to support or refute the association between toothbrushing and gingival recession are inconclusive.

Do preoperative antibiotics prevent dental implant complications

Abstract: The Cochrane Oral Health Group's Trials Registry, the Cochrane Central Register of Controlled Trials, Medline and Embase were consulted to find relevant work. Searches were made by hand of numerous journals pertinent to oral implantology. There were no language restrictions. Randomised controlled clinical trials (RCT) with a followup of at least 3 months were chosen. Outcome measures were prosthesis failures, implant failures, postoperative infections and adverse events (gastrointestinal, hypersensitivity, etc.). Two reviewers independently assessed the quality and extracted relevant data from included studies. The estimated effect of the intervention was expressed as a risk ratio together with its 95% confidence interval (CI). Numbers-needed-to-treat (NNT) were calculated from numbers of patients affected by implant failures. Meta-analysis was done only if there were studies with similar comparisons that reported the same outcome measure. Significance of any discrepancies between studies was assessed by means of the Cochran's test for heterogeneity and the I2 statistic. Only two RCT met the inclusion criteria. Meta-analysis of these two trials showed a statistically significantly higher number of patients experiencing implant failures in the group not receiving antibiotics (relative risk, 0.22; 95% CI, 0.06–0.86). The NNT to prevent one patient having an implant failure is 25 (95%CI, 13–100), based on a patient implant failure rate of 6% in people not receiving antibiotics. The following outcomes were not statistically significantly linked with implant failure: prosthesis failure, postoperative infection and adverse events (eg, gastrointestinal effects, hypersensitivity). There is some evidence suggesting that 2 g of amoxicillin given orally 1 h preoperatively significantly reduces failures of dental implants placed in ordinary conditions. It remains unclear whether postoperative antibiotics are beneficial, and which is the most effective antibiotic. One dose of prophylactic antibiotics prior to dental implant placement might be recommended.

Sequential analysis applied to clinical trials in dentistry: a systematic review.

Abstract: Clinical trials employ sequential analysis for the ethical and economic benefits it brings. In dentistry, as in other fields, resources are scarce and efforts are made to ensure that patients are treated ethically. The objective of this systematic review was to characterise the use of sequential analysis for clinical trials in dentistry. We searched various databases from 1900 through to January 2008. Articles were selected for review if they were clinical trials in the field of dentistry that had applied some form of sequential analysis. Selection was carried out independently by two of the authors. We included 18 trials from various specialties, which involved many different interventions. We conclude that sequential analysis seems to be underused in this field but that there are sufficient methodological resources in place for future applications.

Condylar fractures: is open or closed reduction best?

Abstract: DATA SOURCES Medline was searched and further references were identified from selected papers. STUDY SELECTION Studies were included if they simultaneously compared open and closed techniques with at least one of the following outcome measures: maximum postoperative mouth opening, amount of lateral excursion and protrusion, mandibular deviation on mouth opening, facial symmetry, and joint or muscle pain. They were also required to have had at least 6 months follow-up and have been published in English. DATA EXTRACTION AND SYNTHESIS Meta-analysis was carried out using the weighted average method for fixed effects and the weighted average method for random effects. RESULTS Thirteen studies were included, only one of which was a randomised controlled trial (RCT). Numerous problems were found with the information presented in the various articles. These included lack of patient randomisation, failure to classify the type of condylar fracture, variability within the surgical protocols, and inconsistencies in choice of variables and how they were reported. CONCLUSIONS Because of the great variation in how the various study parameters were reported, it was not possible to perform a reliable meta-analysis. There is a need for better standardisation of data collection in future studies as well as randomisation of the patients treated so that the two approaches can be accurately compared.

No evidence to support one surgical technique over the other for the management of palatally displaced canines.

Abstract: No evidence to support one surgical technique over the other for the management of palatally displaced canines

Root canal therapy, fixed partial dentures and implant-supported crowns, have similar short term survival rates.

Abstract: Searches using the Medline, Cochrane and Embase databases and ‘citation mining’ (identifying references from included studies) were carried out. In addition, experts' recommendations for data sources were followed, and the table of contents of every issue of the most recent 2 years of a given list of dental journals were reviewed, the latter representing half of the total number of original research articles in English from the past 5 years on implant-supported crown (ISC), fixed partial dentures (FPD) and root canal (RC) therapy. Publication language was limited to English and grey literature was excluded, namely proceedings of conferences not listed in Medline, Cochrane or Embase databases, meetings and lectures. Comparative or noncomparative, prospective or retrospective longitudinal data were selected that related to clinical, biological, psychological and economic outcomes, as well as beneficial or harmful effects, of saving teeth by root canal treatment and/or alternative treatments, including: extracting the tooth and leaving an edentulous space or replacing the missing tooth with a fixed-partial-denture or implant-supported tooth. Three pairs of investigators (each team dealing with one of the three main treatment options) independently searched, selected and extracted data for analysis. Tables of evidence were created from articles that met the validity criteria. Each selected paper was given a quality score, where the maximum possible was 17. Discussion and consensus were used to resolve disagreement. Interpretation of the outcome data and classification of data according to success or survival and the type of study were verified by two statisticians. Qualitative and quantitative methods were used to integrate the evidence. The data were analysed by deciding whether and what data to combine, and measuring the statistical heterogeneity of the data using Cochrane Q and I2 statistics. For the purpose of comparison, clinical outcomes were grouped into three time-intervals (2–4 years, 4–6 years and >6 years). Each discipline and followup interval from individual studies were displayed in a Forest plot with Wilson Score 95% confidence intervals. Meta-analysis produced pooled points and weighted averages. Psychosocial and economic outcome data was subjected to narrative review only. The 143 selected studies varied considerably in design, definition of success, assessment methods, operator type and sample size. Direct comparison of treatment types was extremely rare. Limited psychosocial data revealed the traumatic effect of loss of visible teeth. Economic data were largely absent. Success rates for ISC were higher than for RC treatment with direct or indirect restoration and FPD, respectively. Success criteria, however, differed greatly between treatment types, rendering direct comparison of success rates futile. Long-term survival rates for ISC and RC therapy were similar and superior to those for FPD. The lack of studies with similar outcome criteria and comparable time intervals limited the ability to make valid comparisons between these treatments. It was possible to conclude that ISC and RC treatments have superior long-term survival compared with FPD. Limited data suggested that extraction without replacement resulted in inferior psychosocial outcomes compared with alternatives. Long-term prospective clinical trials with large sample sizes and clearly defined outcome criteria are needed.

Pits and fissure sealant guidelines. Summary guideline.

Abstract: The guideline aims to address four clinical questions relating to the use of pit and fissure sealants: Medline was searched for all systematic reviews on pit and fissure sealants, and the reference lists of identified reviews were searched for additional references. A second search was carried out to identify clinical studies published after the systematic review were completed. Publications were included that addressed one or more of the identified clinical questions, had a documented search strategy, and were written in English. An expert panel was convened to evaluate the evidence and develop recommendations. The draft recommendations were submitted to a wide range of scientific experts and organisations for review, following which appropriate changes were made. The evidence was classified and clinical recommendations made using a system modified from the approach taken by Shekell et al.1 The final clinical recommendations were approved by the American Dental Association Council on Scientific Affairs. Plans were not specified for future review and updating of this guideline. Using the evidence grading and recommendation systems described by Shekelle1 (Table 1 and 2) a number of clinical recommendations were made (see summary in Table 3). A number of topics for additional research to improve the evidence base regarding the use of fissure sealants were identified by the expert panels. These are shown in Table 2.

Oral cancer risk and smokeless tobacco products--clouded by smoke?

Abstract: Medline, Embase, Cancerlit, Toxline were searched, followed by the reference lists of identified reviews and articles. Human cohort or case–control studies in peer-reviewed journals or that were publicly available were selected if they specified study location; examined any form of oral cancer as the outcome; and described use of chewing tobacco, orally used moist snuff or unspecified smokeless tobacco as the exposure. Studies in Asian populations and those with insufficient power where risk estimates and confidence intervals were not reported or could not be calculated were excluded. Standard information was abstracted from each study. Whole-population data were used to estimate numbers of never-smokers. Separate figures for males and females were obtained where possible. Estimates were made of effect size and precision since these were not presented in original studies. Separate meta-analyses were conducted for chewing tobacco, for snuff and for overall smokeless tobacco. Sensitivity analyses for smokers/ nonsmokers were carried out. Heterogeneity was investigated and publication bias assessed using a funnel plot. The 32 studies meeting the inclusion criteria provided 38 heterogeneous study-specific estimates of odds or relative risk ratios (see Tables 1, 2). An increase in risk was mainly evident in studies conducted before 1980. No increase was seen in studies in Scandinavia. The pattern of estimates suggests some publication bias. Smokeless tobacco, as used in America or Europe, carries at most a minor increased risk of oral cancer, but elevated risks in specific populations or from specific products cannot definitely be excluded.

No evidence to link prosthetic joint infections with dental procedures.

Abstract: Medline and bibliographies of relevant papers were used to source relevant studies. Case reports and references to relevant conference presentations were also included. Animal and in-vitro studies were excluded. Publications in English, French and German were included. All relevant articles including case studies and references to abstracts of conference presentations were considered. A qualitative summary was made of relevant data. Of 144 articles retrieved, there were 23 prospective studies but no randomised or comparative trials. Twenty-seven reports (18.8%) favoured prophylaxis for special circumstances, 11 publications (7.6%) did not perceive any benefit and 106 (73.6%) took no clear position. I nfections of total hip or knee replacements because of haematogenous seeding following dental intervention are very rare. The scientific rationale for systemic or local antimicrobial prophylaxis is very weak at best.

Do antiviral agents effectively treat Ramsay Hunt syndrome

Abstract: The Cochrane Ear, Nose and Throat Disorders Group Trials Register, the Cochrane Central Register of Controlled Trials, Medline, PubMed, Embase and other relevant databases (Cinhal.LILACS,KoreaMed, IndMed, PakMediNet, theUK Clinical Research Network Portfolio Database (UKCRN), the World Health Organization International Clinical Trials Registry Platform (ICTRP), Google Scholar, NLH ENT & Audiology Specialist Library and the metaRegister of Controlled Trials (mRCT).) were utilised to identify possible trials. Randomised controlled trials (RCT) were eligible for inclusion if antiviral agents alone or in combination with other therapies (using different routes of administration and dosage schemes) had been taken as treatment for Ramsay Hunt syndrome. Two reviewers independently assessed eligibility and trial quality. Only one RCT was identified and included. It was of low quality and included only 15 participants. In this 1992 trial, treatment with intravenous aciclovir and corticosteroids was compared with corticosteroids alone. Analysis found no statistically significant difference between the two groups. The use of antiviral agents against herpes zoster infections in other parts of the body suggests that they could be useful in the case of herpes zoster oticus. We found no evidence that they have a beneficial effect on outcomes in Ramsay Hunt syndrome, despite their widespread use in this condition. As usual, however, the absence of positive evidence of benefit (or, in this case, the 'negative' result of one small, statistically underpowered study) does not necessarily indicate that antivirals are ineffective. The results of the review do suggest that the various adverse effects of antivirals should be taken into consideration in the risk–benefit analysis that foregoes treatment.