Evidence Based Dentistry Tools
Prioritization of reviews of the Cochrane Oral Health Group
T. WALSH1, H. WORTHINGTON2, J. CLARKSON3, and A. GLENNY2, 1University of manchester, Manchester, England, 2University of Manchester, Manchester, England, 3University of Dundee, Dundee, Scotland
Objective: Systematic reviews play an important role in synthesising information from randomised controlled trials. As of January 2014 Cochrane Oral Health Group (COHG) has published 145 systematic reviews (over half have subsequently been updated) and 63 protocols. Further reviews and protocols are in preparation.
An important aspect of COHGs work is to ensure that reviews we publish are high quality, and address clinical questions that are important, timely and relevant to practice. COHG recently undertook international prioritization exercises in the dental specialties orthodontics and paediatrics. The results were to be used by the editorial team to ensure timely production and updating of important reviews.
Method: In separate processes, COHG invited all registered authors of orthodontic and paediatric reviews to rank in order of importance a ‘top 10’ from a list of published Cochrane systematic review titles, protocols or full reviews. Individual rankings were collated and an overall ranking of review titles was produced. A smaller panel of experts then discussed the results. The expert panel were also able to contribute titles that were not in the overall top 10.
Result: The expert panels ratified author rankings and provided additional topics. For orthodontic reviews, the highest rankings were attributed to the effectiveness of specific orthodontic interventions. Additional topics identified by the expert panel included harms of orthodontic treatment. For paediatric reviews, the highest rankings were for the management of caries. Additional topics included prevention and treatment of dental fear and anxiety (author additions), and community based interventions for preventing caries.
Conclusion: The prioritisation exercises have been invaluable in ensuring that COHG provide a timely and clinically relevant evidence base. The next stage in this work is to assimilate the rankings of consumers in these areas, and to extend the prioritisation work to other dental specialties such as periodontology and restorative dentistry.
Synthesis of multiple Cochrane review meta-analyses for patients' oral self-care
P. RILEY1, H. WORTHINGTON1, J. CLARKSON2, and A. GLENNY1, 1University of Manchester, Manchester, England, 2University of Dundee, Dundee, Scotland
People need to know how best to manage their own oral health. They may wonder whether to use an antibacterial toothpaste, whether to floss or use interdental brushes, and whether to use a manual or powered toothbrush.
Objective: To synthesise the data from multiple meta-analyses for oral self-care to enable clinical decisions to be made by patients.
Method: The body of evidence from four existing Cochrane reviews (flossing, interdental brushes, manual versus powered toothbrushes, antibacterial toothpaste), consisting of randomised controlled trials only, was considered. We extracted the data for the most commonly used indices for plaque (Turesky modification of Quigley-Hein Plaque Index: 0-5 scale) and gingivitis (Loe-Silness Gingival Index: 0-3 scale). Mean differences for each intervention at short (1-3 months) and long-term (6 months or more) time-points were extracted from the published review, along with the GRADE rating of the quality of the body of evidence for each outcome/intervention, where this had been assessed.
Result: For three of the reviews there were few trials reporting the same indices, with less data for the clinical outcome (gingivitis), long-term outcomes, and GRADE ratings generally ‘low’ or ‘very low’ if assessed. The fourth review looking at triclosan toothpaste had the largest mean differences for both plaque -0.47 (95% CI -0.60 to -0.34) and gingivitis -0.27 (95% CI -0.33 to -0.21) at 6-9 months. This was the strongest body of available evidence both in terms of numbers of trials (20) and GRADE rating of moderate.
Conclusion: The inconsistencies in the reporting of clinical indices is a barrier to making clinical decisions for most of the interventions considered. The strongest evidence for gingival health is to use an antibacterial toothpaste. The clinical significance of the indices reported needs discussion by both periodontists and methodologists.
Non-Conventional Statistical Methods for Analysis of Clustered Clinical Data
S. SAMITA1, P.S. RAJAPAKSE1, J. HOWSHIGAN1, and J.S. JAYAWEERA2, 1University of Peradeniya, Peradeniya, Sri Lanka, 2Rajarata University of Sri Lanka, Saliyapura, Sri Lanka
Objective: Evaluation of a conventional statistical method; linear logistic model (LLM), and an alternative method; modified LLM, in the analysis of clustered binary clinical data.
Method: Bleeding on probing data (two sets; buccal and lingual) recorded as binary data at baseline and at 24 weeks , in a clinical trial on gingivitis patients on the efficacy of a herbal dentifrice and a placebo(n=32/gp) was used in this study. Data was analyzed using LLM, and a modified LLM where another parameter was introduced to account for extra–variability- encountered due to clustering of data. With both models, statistics from fitting the saturated model (model with all possible terms) were considered.
Results: The goodness of fit statistic deviance (G2) for the LLM and modified LLM for the lingual dataset were 562.46 with 124 degrees of freedom (df) (P<0.0001) and 122.00 with 124 df (P=0.5340) respectively. The LLM contained four parameter estimates and the standard errors of those were 0.5834, 0.3517, 0.3251 and 0.2007. The corresponding standard errors from the modified LLM were 1.2526, 0.7552, 0.6981 and 0.4310. Similarly, with the buccal dataset, G2values for the LLM and modified LLM were 567.07 with 124 df (P<0.0001) and 123.00 with 124 df (P=0.4832) respectively. The set of standard errors from the standard LLM were 0.5440, 0.3397, 0.3080 and 0.1975 and, the corresponding set from modified LLM were 1.1681, 0.7295, 0.6613 and 0.4211.
According to G2and the corresponding probabilities modified LLM is far superior to the LLM. Further, the standard errors have clearly been underestimated with standard LLM. With extra–variability, standard errors have to be larger and those have been more correctly estimated with the modified LLM.
Conclusion: In analyzing clustered clinical data LLM may not be appropriate and it may provide erroneous statistics. The modified LLM could be considered under such circumstances.
Clinical Practice Based on Scientific Evidence
Caries preventive measures: Meta-summary
U.S.G. SUGA1, C.G. RODRIGUES2,3, A.L.M. UBALDINI4, M. FUJIMAKI4, R.C. PASCOTTO1, A.P. BATILANA5, R. PIETROBON5, J.R.N. VISSOCI6, and R.S.S. TERADA4, 1State University of Maringa, Maringa, Brazil, 2Instituto de Cardiologia do RS / Fundação Universitária de Cardiologia (IC-FUC), Porto Alegre, Brazil, 3Duke University, Durham, NC, 4State University of Maringá, Maringá, Brazil, 5Duke University Medical Center, Durham, NC, 6Faculdade Ingá, Maringa, Brazil
Objective: This study aimed to evaluate the factors that drive dentists towards or away from dental caries preventive measures.
Method: The PubMed, EMBASE, PsycINFO, Scielo, Scopus, Web of Science, BBO, Lilacs and York databases were searched. Reference lists and citations of the selected studies were also searched. Two reviewers independently assessed titles, abstracts and full texts to determine study eligibility. Publications meeting the inclusion criteria were assessed for quality, and the data were extracted. Descriptive analysis of included publications was conducted, and themes were created to permit analysis by grouping relevant findings, from which effect size frequency (ESF) and effect size intensity (ESI) were calculated.
Result: The search yielded 18,276 titles and abstracts, of which seven qualitative studies and 41 surveys (36,632 participants) remained after data extraction and interpretation. The main themes identified by their ESF were biologicism (27%), low pay for preventive procedures (25%), time since graduation (22%), teamwork (21%), male dentists (19%), patients’ lack of awareness of the importance of prevention (17%), difficulty in treating small children (12%), professional development (12%), awareness of prevention benefits (10%), preventive education (10%), and motivation of parents (4%). Methodological quality varied widely among studies.
Conclusion: The primary factors that drove dentists away from performing preventive measures were biologicism, low pay for preventive procedures, time since graduation, being a male dentist, lack of patient awareness, and difficulty in treating small children. Factors that drive towards prevention were teamwork, postgraduate education, awareness of preventive benefits, preventive education and motivation of parents. The study results can be used for planning and decision making to drive changes in professional practice that will result in the improvement of oral health care in the general population.
Treatment for Exfoliative Cheilitis: A Meta-Analysis
W. JIANG, and K. SUN, Shanghai Ninth People’s Hospital, College of Stomatology, Shanghai Jiao Tong University School of Medicine, Shanghai, China
Objective: To evaluate and assess the treatment for patients with exfoliative cheilitis (EC) and to provide evidence-based management of EC.
Method: "exfoliative cheilitis", "scaling cheilitis", "factitious cheilitis" were used as keywords to retrieve data from January 1st, 1962 to July 31st, 2013 in Pubmed, Cochrane Central Register of Controlled Trials and Wanfang Database. We included randomized controlled trials (RCTs) and case series of treating patients with EC. Drugs included in the search were corticosteroids, vitamin, antibiotics, traditional Chinese medicine (TCM), and other topical drugs (urea, glycerol). Only data of publication in English and Chinese was recruited.
Result: Fifteen RCTs and 25 case series were found. The TCM used had the properties of clearing heat and included 3 subgroups: eliminating toxin, resolving dampness, and nourishing Yin. Three RCTs involving 223 participants have been included for meta-analysis of TCM vs corticosteroids. Total benefit in TCM and corticosteroids was 93.02% and 85.11%. The relative risk (RR) was 1.098 [95% confidence interval (CI): 0.996-1.210, p=0.060]. It indicates that TCM is an alternative approach for patients with EC. Four RCTs involving 205 participants have been included for meta-analysis of integrative TCM and western medicine (ITW) vs western medicine. Total benefit in ITW group and western medicine group was 93.20% and 71.57%. The RR was 1.303 (95% CI: 1.142-1.486, p<0.001). It suggests that ITW is a better option for patients with EC.
Conclusion: TCM is an alternative approach for patients with EC. ITW is better than western medication for treating patients with EC.
Critical analysis of controlled clinical trials published in dental spanish journals
J. VILLANUEVA1, I. DELGADO2, C. MARTIN2, H. PARDO3, and X. BONFILL3, 1University of Chile, Santiago, Chile, 2Universidad Complutense Madrid, Madrid, Spain, 3Centro Cochrane Iberoamericano, Barcelona, Spain
Objective: The aim of this study was to identify controlled clinical trials (CCT) published in dentistry journals from Spain, as well as to assess their methodological quality, with an emphasis on their design and reporting of results
Method: A retrospective electronic and hand search of the available literature was conducted, starting in 2011, of 37 dentistry journals from Spain. A descriptive analysis of the main characteristics of the identified CCTs was performed, followed by an assessment of their methodological quality using the Cochrane Collaboration’s tool for assessing risk of bias
Result: A total of 84 CCTs published in 14 of the 37 included journals between 1989 and 2011 were identified. Of these CCTs, 58 % were conducted in Spain. In general, there were methodological deficiencies in the design of the CCTs, which could potentially entail biases in their results. When using the Cochrane Collaboration’s tool for assessing risk of bias, the best ratings were awarded to fields related to missing outcome data, whereas the worst were for blinding of participants and key study personnel. No relationship between study quality and publication date of results were noted.
Conclusion: It is necessary to promote research in dentistry in Spain and the development of more clinical trials in this area. Minimizing potential sources of bias and accurately reporting all methodological aspects could improve the quality of CCTs published in dentistry journals from Spain.
Systematic review: Exercise therapy and massages for Oral Myofacial Pain
C. ROLDÁN B.1, S. JANKO1, and H. LAUER2, 1J.W.Goethe-Universität Frankfurt am Main, Frankfurt am Main, Germany, 2J.W. Goethe University, Frankfurt, Germany
Objective: to evaluate the effectiveness of exercise therapy and massages for the treatment of oral myofascial pain.
Method: a systematic review and meta-analysis of RCTs on exercise therapy and massages for myofacial pain was conducted. Scientific literature from 1999 to 2012 (MEDLINE via PubMed, Cochrane CENTRAL, and other sources) was searched in order to identify RCTs on exercise therapy and massages for the treatment of myofacial pain in adults. Two review authors compiled and evaluated the included studies. The studies were compared within two categories, namely single or combined interventions.
Result: 13 RCTs (n=820) with a high heterogeneity in treatment modalities and outcomes were analyzed. Significant differences (p<.001) were observed for short-term maximal jaw opening within combined interventions including exercise therapy and/or massages. Moreover, single interventions of jaw exercises were more effective (p=.05) than control groups to relieve pain at short-term.
Conclusion: In this review, the quality of the reports prevents us from concluding on the effectiveness of the treatment. However, in a limited number of good quality studies we observed a tendency to show a boosted action of psychosocial interventions combined with exercise therapy.
The goal of evidence-based dentistry (EBD) is to promote the use of best evidence in clinical dentistry.
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