The assessment of systematic reviews in dentistry

The aim of this study was to assess the quality of systematic reviews of effectiveness of interventions in dentistry. The Database of Abstracts of Reviews of Effectiveness and the Cochrane Database of Systematic Reviews were searched to identify systematic reviews examining the effectiveness of interventions for oral, dental and craniofacial disorders and diseases. Sixty-five reviews were identified and assessed independently by two reviewers. The area most frequently evaluated within the reviews was pain relief/prevention (20/65, 31%) followed by caries and oral medicine. The quality assessment of the identified systematic reviews highlighted key areas where improvements could be made. One major weakness of the reviews was that the search strategies employed were not always adequate. Only 12 reviews (19%) demonstrated an attempt to identify all relevant studies. Other areas of weakness include the screening and quality assessment of primary studies, the pooling of data and examination of heterogeneity, and the interpretation of findings. This investigation shows that the quality of systematic reviews in dentistry could be improved. If future clinical decisions are to be based upon systematic reviews, it is imperative that the reviews address clinically relevant, focused questions and follow a 'transparent', well-designed protocol.

Systematic review of ceramic inlays

The purpose of the present study was to conduct a systematic review of ceramic inlays, assess the quality of published clinical studies, and determine the clinical effectiveness of ceramic inlays compared to other forms of posterior restorations. Prospective clinical trials of ceramic inlays published from 1990 to 2001 were retrieved by electronic and hand searching. The methodological quality of each study was assessed by two calibrated reviewers using a standardised checklist. The clinical effectiveness of ceramic inlays was evaluated in terms of failure rate, postoperative pain, and aesthetics. The results were compared to those of other forms of posterior restorations by means of an odds ratio. Among 46 articles selected for quality assessment, only five (10.6%) reported randomised controlled trials and 15 (32.6%) presented controlled clinical trials. The remaining 26 papers (56.5%) were longitudinal clinical trials lacking control groups. Only three papers fulfilled the requirement for statistical analysis to evaluate the clinical effectiveness of ceramic inlays. The results indicate no significant differences in longevity or postoperative sensitivity between ceramic and other posterior restorations over assessment periods of up to 1 year. It is concluded that no strong evidence is available to confirm the clinical effectiveness of ceramic inlays in comparison to other posterior restorations. Greater attention is required to the design and reporting of studies to improve the quality of clinical trials of ceramic inlays.

Factors associated with health care seeking behaviour for orofacial pain in the general population

OBJECTIVE

To describe the health care seeking behaviour associated with orofacial pain (OFP) and determine factors associated with such behaviour.

DESIGN

Cross-sectional population-based study using postal questionnaires.

PARTICIPANTS

Adults aged 18-64 years from a general medical practice in south-east Cheshire, UK (participation rate 74%).

RESULTS

Of the 2,504 respondents to the questionnaire 646 reported OFP, of whom 555 (86%) indicated whether or not they sought professional help. A total of 255 (46%) responded that they had sought advice. The majority had sought advice from their medical practitioner (57%) or dentist (51%), and 64% had taken medication because of OFP. The likelihood of seeking treatment increased linearly with age (p < 0.001) while gender, education and psychological distress did not show a significant association with seeking treatment. Persons who were regular dental attenders had an increased likelihood of seeking treatment for OFP (RR 1.4; 95% CI 1.1,1.8). Perception of illness had moderate association with healthcare seeking (RR 0.8; 95% CI 0.7,0.96). There was a significant trend of increasing RR with increasing total number of pain symptoms (p < 0.001), frequency of pain, duration of pain episodes, pain intensity and disability associated with pain. Participants who reported pain duration of more than three months had almost double the likelihood (RR 1.8; 95% CI 1.4,2.3) of seeking treatment. Decrease in self-reported control over pain and ability to decrease pain were both associated with an increased likelihood of seeking professional care (p < 0.001).

CONCLUSIONS

The strongest predictors of health care seeking behaviour were different characteristics of pain.

Interventions for replacing missing teeth: different times for loading dental implants

BACKGROUND

To minimize the risk of implant failure, osseointegrated oral implants are conventionally kept load-free during the healing period. During healing removable prostheses are used, however many patients find these temporary prostheses rather uncomfortable and it would be beneficial if the healing period could be shortened without jeopardizing implant success. Nowadays immediate and early loaded implants are commonly used in mandibles of good bone quality. It would be useful to know whether there is a difference in success rates between immediately or early loaded implants compared with conventionally loaded implants.

OBJECTIVES

To test the null hypothesis of no difference in the clinical performance between osseointegrated implants loaded at different times one year after loading.

SEARCH STRATEGY

The Cochrane Oral Health Group Trials Register, The Cochrane Central Register of Controlled Trials, MEDLINE and EMBASE were searched. Handsearching included several dental journals. Authors of all identified trials and 55 oral implant manufacturers were contacted to find unpublished RCTs. The last electronic search was conducted on 8 May 2002.

SELECTION CRITERIA

All RCTs of root-form osseointegrated oral implants having a follow-up of one year comparing the same osseointegrated root-form oral implants loaded at different times.

DATA COLLECTION AND ANALYSIS

Data were independently extracted, in duplicate, by two reviewers. Authors were contacted for details of randomization and withdrawals and a quality assessment was carried out. The Cochrane Oral Health Group's statistical guidelines were followed.

MAIN RESULTS

Only three RCTs were identified and two trials including 68 patients in total were suitable for inclusion in this review. Implants have been either immediately loaded after insertion (two to three days), early loaded (six weeks) or conventionally loaded (three to eight months) in edentulous mandibles of adequate bone quality and shape. On a patient, rather than per implant basis, there were no statistically significant differences for prosthesis failures, implant failures and marginal bone loss on intra-oral radiographs.

REVIEWER'S CONCLUSIONS

While it is possible to successfully load oral implants immediately after their placement in mandibles of adequate bone density and height of carefully selected patients, it is yet unknown how predictable this approach is. More well designed RCTs are needed to understand how predictable immediate and early loading are. Such trials should be simply designed and should be reported according to the CONSORT guidelines (http://www.consort-statement.org/). It is suggested that priority should be given to trials assessing the effectiveness of immediately loaded implants rather than early loaded ones.

Interventions for replacing missing teeth: bone augmentation techniques for dental implant treatment

BACKGROUND

Dental implants require sufficient bone to adequately stabilise. For some patients implant treatment would not be an option without bone augmentation. A variety of materials and surgical techniques are available for use in bone augmentation.

OBJECTIVES

To test the null hypothesis of no difference in the success, function, morbidity and patient satisfaction between different bone augmentation techniques for dental implant treatment.

SEARCH STRATEGY

The Cochrane Oral Health Group's Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE were searched. Several dental journals were handsearched. The bibliographies of review articles were checked, and personal references were searched. Implant manufacturing companies were also contacted.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of different techniques and materials for augmenting bone for implant treatment.

DATA COLLECTION AND ANALYSIS

Quality assessment was carried out and authors were contacted for any missing information. Data were independently extracted in duplicate.

MAIN RESULTS

Four RCTs (n = 95) were suitable for inclusion in this review, assessing three different aspects of bone augmentation techniques: onlay grafting with and without a barrier membrane, grafting with a resorbable and non-resorbable membrane, and membranes for guided bone regeneration (GBR). Trials reported on augmentation procedures up to abutment connection only. At the patient level there were no statistically significant differences for the alternative techniques for onlay grafting with respect to the degree of bone graft resorption and wound dehiscence. One trial showed statistically significantly more infections in the non-resorbable group compared to the resorbable group, relative risk 0.05 (95% confidence interval (CI): 0.00 to 0.74). One study of GBR with a resorbable versus non-resorbable membrane indicated no statistically significant difference in early implant failure, reduction in bone defect or wound dehiscence. The other GBR study compared a non-resorbable membrane with no membrane and reported no statistically significant difference in wound infection or dehiscence but a significant increase in per cent bone gain for the test group compared to control, mean difference = 70 (95% CI: 36 to 104, p = 0.002).

REVIEWER'S CONCLUSIONS

There is no evidence from available RCTs supporting superior success with one or other of the alternative techniques examined. There was weak evidence that a non-resorbable membrane was better than no membrane for permitting bone growth about dental implants, and that a resorbable membrane over a bone graft may allow healing with fewer infections than a non-resorbable membrane.

Adhesives for fixed orthodontic brackets

BACKGROUND

Bonding of orthodontic brackets to teeth is important to enable effective and efficient treatment with fixed appliances. The problem is bracket failure during treatment which increases operator chairside time and lengthens treatment time. A prolonged treatment is likely to increase the oral health risks of orthodontic treatment with fixed appliances one of which is irreversible enamel decalcification.

OBJECTIVES

To evaluate the effectiveness of different orthodontic adhesives for bonding.

SEARCH STRATEGY

Electronic databases: the Cochrane Oral Health Group's Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE. Date of most recent searches: August 2002 (CENTRAL) (The Cochrane Library Issue 2, 2002).

SELECTION CRITERIA

Trials were selected if they met the following criteria: randomised controlled trials (RCTs) and controlled clinical trials (CCTs) comparing two different adhesive groups. Participants were patients with fixed orthodontic appliances. The interventions were adhesives that bonded stainless steel brackets to all teeth except the molars. The primary outcome was debond or bracket failure.

DATA COLLECTION AND ANALYSIS

Data were recorded on decalcification as a secondary outcome, if present. Information regarding methods, participants, interventions, outcome measures and results were extracted in duplicate by pairs of reviewers (Nicky Mandall (NM) and Rye Mattick (CRM); Declan Millett (DTM) and Joy Hickman (JH2)). Since the data were not presented in a form that was amenable to meta-analysis, the results of the review are presented in narrative form only.

MAIN RESULTS

Three trials satisfied the inclusion criteria. A chemical cured composite was compared with a light cure composite (one trial), a conventional glass ionomer cement (one trial) and a polyacid-modified resin composite (compomer) (one trial). The quality of the trial reports was generally poor.

REVIEWER'S CONCLUSIONS

It is difficult to draw any conclusions from this review, however, suggestions are made for methods of improving future research involving orthodontic adhesives.

Enamel matrix derivative (Emdogain) for periodontal tissue regeneration in intrabony defects

BACKGROUND

Periodontitis is a chronic infective disease of the gums caused by bacteria present in dental plaque. This condition induces the breakdown of the tooth supporting apparatus until teeth are lost. Surgery may be indicated to arrest disease progression and regenerate lost tissues. Several surgical techniques have been developed to regenerate periodontal tissues including guided tissue regeneration (GTR), bone grafting (BG) and the use of enamel matrix derivative (EMD). EMD is an extract of enamel matrix and contains amelogenins of various molecular weights. There is evidence to show that amelogenins are involved not only in enamel formation, but also in the formation of the periodontal attachment during tooth formation.

OBJECTIVES

To test the efficacy of EMD in comparison with open flap debridement, GTR and various BG procedures for the treatment of intrabony defects.

SEARCH STRATEGY

We searched the Cochrane Oral Health Group's Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE. Several journals were handsearched. No language restrictions were applied. Authors of randomised controlled trials (RCTs) identified, personal contacts and the manufacturer were contacted to identify unpublished trials. Most recent search: January 2003.

SELECTION CRITERIA

RCTs on patients affected by periodontitis having intrabony defects treated with EMD compared with open flap debridement, GTR and various BG procedures with at least one year follow up. The outcome measures considered were: tooth loss, changes in probing attachment levels (PAL), pocket depths (PPD), gingival recessions (REC), marginal bone levels on intraoral radiographs and postoperative infections.

DATA COLLECTION AND ANALYSIS

Screening of eligible studies, assessment of the methodological quality of the trials and data extraction were conducted in duplicate and independently by two reviewers. Results were expressed as random effect models using weighted mean differences for continuous outcomes and relative risk for dichotomous outcomes with 95% confidence interval (CI). Heterogeneity was investigated including both clinical and methodological factors.

MAIN RESULTS

No difference in tooth loss was observed. A meta-analysis including eight trials showed that Emdogain treated sites displayed statistically significant PAL improvements (mean difference 1.3 mm, 95%CI: 0.8 to 1.8) and PPD reduction (1 mm, 95%CI: 0.5 to 1.4) when compared to flap surgery. Comparing Emdogain with GTR (six trials), GTR showed a statistically significant reduction of PPD (0.6 mm) and increase of REC (0.5 mm). No difference in postoperative infections was observed.

REVIEWER'S CONCLUSIONS

Emdogain is able to significantly improve PAL levels (1.3mm) and PPD reduction (1mm) when compared to flap surgery, however these results may not have a great clinical impact, since it has not been shown that more periodontally compromised teeth could be saved. There was no evidence of clinically important differences between GTR and Emdogain.

Antibiotics to prevent complications following dental implant treatment

BACKGROUND

Some dental implant failures may be due to bacterial contamination at implant insertion. Infections around biomaterials are difficult to treat and almost all infected implants have to be removed. In general, antibiotic prophylaxis in surgery is only indicated for patients at risk of infectious endocarditis, for patients with reduced host-response, when surgery is performed in infected sites, in cases of extensive and prolonged surgical interventions and when large foreign materials are implanted. To minimise infections after dental implant placement various prophylactic systemic antibiotic regimens have been suggested. More recent protocols recommended short term prophylaxis, if antibiotics have to be used. With the administration of antibiotics adverse events may occur, ranging from diarrhoea to life-threatening allergic reactions. Another major concern associated with the widespread use of antibiotics is the selection of antibiotic-resistant bacteria. The use of antibiotics in implant dentistry is controversial. It would be useful to know whether prophylactic antibiotics are effective in reducing failures of dental implants.

OBJECTIVES

To assess the beneficial or harmful effects of the administration of prophylactic antibiotics for dental implant placement versus no antibiotic/placebo administration and if antibiotics are of benefit, to find which type, dosage and duration is the most effective.

SEARCH STRATEGY

We searched the Cochrane Oral Health Group's Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE. We handsearched several dental journals. No language restrictions were applied. Personal contacts and manufacturers of dental implants were contacted to identify unpublished trials. Most recent search: March 2003.

SELECTION CRITERIA

Randomised controlled clinical trials (RCTs) with a follow up of at least 3 months comparing the administration of various prophylactic antibiotics regimens and no antibiotics/placebo to patients undergoing dental implant placement. Outcome measures were prosthesis failures, implant failures, postoperative infections and adverse events (gastrointestinal, hypersensitivity).

DATA COLLECTION AND ANALYSIS

Screening of eligible studies, assessment of the methodological quality of the trials and data extraction were to be conducted in duplicate and independently by two reviewers. Results were to be expressed as random effects models using weighted mean differences for continuous outcomes and relative risk for dichotomous outcomes with 95% confidence interval. Heterogeneity was to be investigated including both clinical and methodological factors.

MAIN RESULTS

No RCTs were identified.

REVIEWER'S CONCLUSIONS

There is not appropriate scientific evidence to recommend or discourage the use of prophylactic systemic antibiotics to prevent complications and failures of dental implants. Even though the present review did not assess the effectiveness of prophylactic antibiotics for patients at risk for endocarditis, it seems sensible to recommend the use of prophylactic antibiotics for patients at high and moderate risk for endocarditis, with immunodeficiencies, metabolic diseases, irradiated in the head and neck area and when an extensive or prolonged surgery is anticipated.

Interventions for replacing missing teeth: surgical techniques for placing dental implants

BACKGROUND

Many variations in the surgical technique for the placement of dental implants have been developed since the introduction of implant surgery into clinical practice. These include variations in the timing of implant placement in relation to the tooth removal, and variations in the way the recipient bone site is prepared, amongst others.

OBJECTIVES

To test the null hypothesis of no difference in the success, function, morbidity, patient satisfaction and cost-effectiveness of different surgical techniques for placing dental implants, against the alternative hypothesis of a difference.

SEARCH STRATEGY

The Cochrane Oral Health Group Trials Register, the Cochrane Central Register of Controlled Trials, MEDLINE and EMBASE were searched. In addition, the bibliographies of review articles were checked for studies outside the handsearched journals and personal references were searched. 55 implant companies were also contacted.

SELECTION CRITERIA

Randomised controlled clinical trials (RCTs) of implant surgical techniques.

DATA COLLECTION AND ANALYSIS

Authors were contacted for details of randomisation and data and quality assessment was carried out (ME, PC). Data were independently extracted, in duplicate, by two reviewers (HW, PC). The Cochrane Oral Health Group's statistical guidelines were followed.

MAIN RESULTS

Four RCTs (six publications) were suitable for inclusion in this review of the nine RCTs (11 publications) identified. Two different aspects of implant surgical technique were reported in these RCTs. These were, two versus four implants to support a mandibular overdenture and crestal versus vestibular incision for implant placement. At the patient level there were no statistically significant differences for any of these alternative techniques with respect to implant failures, marginal bone levels, morbidity or patient satisfaction.

REVIEWER'S CONCLUSIONS

This review included studies evaluating the surgical techniques of two versus four implants to support a mandibular overdenture and crestal versus vestibular incision for implant placement. Based on the available results of RCTs, there is no strong evidence supporting superior success with one or other of the alternative techniques for either of these two aspects of surgical technique. These conclusions are based on a few RCTs for each aspect of surgical technique and some with relatively short follow-up periods and few patients.

Manual versus powered toothbrushing for oral health

BACKGROUND

Specific oral bacteria, generically known as "dental plaque" are the primary cause of gingivitis (gum disease) and caries. The removal of dental plaque is thought to play a key role in the maintenance of oral health. There is conflicting evidence for the relative merits of manual and powered toothbrushing in achieving this.

OBJECTIVES

To compare manual and powered toothbrushes in relation to the removal of plaque, the health of the gingivae, staining and calculus, dependability, adverse effects and cost.

SEARCH STRATEGY

We searched the Cochrane Oral Health Group's Trials Register (to 22/8/02); Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 3, 2002); MEDLINE (January 1966 to week 5 2002); EMBASE (January 1980 to week 3 July 2002) and CINAHL (January 1982 to June 2002). Manufacturers of powered toothbrushes were contacted for additional published and unpublished trials.

SELECTION CRITERIA

Trials were selected if they met the following criteria: design-random allocation of participants; participants-general public with uncompromised manual dexterity; intervention- supervised manual and powered toothbrushing for at least four weeks; primary outcomes-the change in plaque and gingivitis over that period.

DATA COLLECTION AND ANALYSIS

Six reviewers independently extracted information in duplicate. Indices for plaque and gingivitis were expressed as standardised values for each study. The effect measure for each meta-analysis was the standardised mean difference (SMD) with the appropriate 95% confidence intervals (CI) using random effect models. Potential sources of heterogeneity were examined, along with sensitivity analyses for the items assessed for quality and publication bias.

MAIN RESULTS

Twenty-nine trials, involving 2,547 participants, provided data for the meta-analysis. Brushes that worked with a rotation oscillation action removed more plaque and reduced gingivitis more effectively than manual brushes in the short and long term. For plaque at one to three months the SMD was -0.44 (95% CI: -0.66 to -0.21), for gingivitis SMD -0.44 (95% CI: -0.72, -0.15). These represented an 11% reduction on the Quigley Hein plaque index and a 6% reduction on the Löe and Silness gingival index. At over three months the effects were SMD for plaque -1.15 (95% CI: -2.02,-0.29) and SMD for gingivitis -0.51 (95% CI: -0.76, -0.25). These represented a 7% reduction on the Quigley Hein Plaque Index and a 17% reduction on the Ainamo Bay Bleeding on Probing Gingival Index. The heterogeneity found in these meta-analyses for short term trials was caused by one trial that had exceptionally low standard deviations. Sensitivity analyses revealed the results to be robust when selecting trials of high quality. There was no evidence of any publication bias. No other powered brush designs were consistently superior to manual toothbrushes. In these trials, data on cost, reliability and side effects were inconsistently reported. Those side effects that were reported on in the trials were localised and temporary.

REVIEWER'S CONCLUSIONS

Powered toothbrushes with a rotation oscillation action achieve a modest reduction in plaque and gingivitis compared to manual toothbrushing. Observation of methodological guidelines and greater standardisation of design would benefit both future trials and meta-analyses.

Interventions for replacing missing teeth: dental implants in zygomatic bone for the rehabilitation of the severely deficient edentulous maxilla

BACKGROUND

Dental implants are used for replacing missing teeth. However, the possibility of placing dental implants is limited by the presence of adequate bone volume permitting their anchorage. Several bone grafting procedures have been developed to solve this problem. The missing bone can be taken from a donor site, transplanted where needed and then implants are placed. Major bone grafting operations have to be undertaken under general anaesthesia and patients have to be hospitalized for a few days. Some degree of morbidity related to the donor site must be expected and two to three surgical interventions are needed before the implants can be functionally used. Often patients have to wait more than 1 year before a denture can be fixed to the implants and the total cost of the treatment is high. However, the major problem is that about 25% of the implants placed in grafted bone fail. Zygomatic implants are long screw-shaped implants developed as an alternative to bone grafting. Zygomatic implants are inserted into the body of the zygomatic bone. Their main advantages are that bone grafting may not be needed and patients may be fitted with a fixed denture much sooner.

OBJECTIVES

To test the hypothesis of no difference in outcomes between zygomatic implants without bone augmenting procedures in comparison with conventional dental implants in augmented bone for severely resorbed maxillae.

SEARCH STRATEGY

We searched the Cochrane Oral Health Group's Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE. We handsearched several dental journals. No language restrictions were applied. Personal contacts and manufacturers of dental implants were contacted to identify unpublished trials. Most recent search: February 2003.

SELECTION CRITERIA

Randomised controlled clinical trials (RCTs) on patients with severely resorbed maxillae who could not be rehabilitated with conventional dental implants, treated with zygomatic implants without bone grafts versus conventional dental implants with bone grafts or other procedures for bone augmentation with a follow up of at least 1 year. Outcome measures considered were: prosthesis and implant failures, side effects, patient satisfaction and cost effectiveness.

DATA COLLECTION AND ANALYSIS

Screening of eligible studies, assessment of the methodological quality of the trials and data extraction were to be conducted in duplicate and independently by two reviewers. Results were to be expressed as random effects models using weighted mean differences for continuous outcomes and relative risk for dichotomous outcomes with 95% confidence interval. Heterogeneity was to be investigated including both clinical and methodological factors.

MAIN RESULTS

No RCTs or controlled clinical trials (CCTs) were identified.

REVIEWER'S CONCLUSIONS

There is an urgent need for RCTs in this area, since zygomatic implants, if found to be at least as effective as other augmentation procedures, may involve major advantages for both patients and society.

Interventions for preventing oral mucositis for patients with cancer receiving treatment

BACKGROUND

Treatment of cancer is increasingly more effective but is associated with short and long term side effects. Oral side effects remain a major source of illness despite the use of a variety of agents to prevent them. One of these side effects is oral mucositis (mouth ulcers).

OBJECTIVES

To evaluate the effectiveness of prophylactic agents for oral mucositis in patients with cancer receiving treatment, compared with other potentially active interventions, placebo or no treatment.

SEARCH STRATEGY

The Cochrane Oral Health Group's Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE were searched. Reference lists from relevant articles were scanned and the authors of eligible studies were contacted to identify trials and obtain additional information. Date of most recent searches June 2002.

SELECTION CRITERIA

Trials were selected if they met the following criteria: design - random allocation of participants; participants - anyone with cancer receiving chemotherapy or radiotherapy treatment for cancer; interventions - agents prescribed to prevent oral mucositis; outcomes - prevention of mucositis, pain, amount of analgesia, dysphagia, systemic infection, length of hospitalisation, cost and patient quality of life.

DATA COLLECTION AND ANALYSIS

Information regarding methods, participants, interventions and outcome measures and results were independently extracted, in duplicate, by two reviewers. Authors were contacted for details of randomisation and withdrawals and a quality assessment was carried out. The Cochrane Oral Health Group statistical guidelines were followed and relative risk values calculated using random effects models.

MAIN RESULTS

One hundred and nine studies were eligible. Fifty-seven were excluded for various reasons, usually as there was no useable information on mucositis. Of the 52 useable studies all had data for mucositis comprising 3594 randomised patients. Interventions evaluated were: acyclovir, allopurinol mouthrinse, amifostine, antibiotic pastille or paste, benzydamine, camomile, chlorhexidine, clarithromycin, folinic acid, glutamine, GM-CSF, hydrolytic enzymes, ice chips, oral care, pentoxifyline, povidone, prednisone, propantheline, prostaglandin, sucralfate and traumeel. Of the 21 interventions included in trials, nine showed some evidence of a benefit (albeit sometimes weak) for either preventing or reducing the severity of mucositis. Interventions where there was more than one trial and a significant difference compared with a placebo or no treatment were allopurinal with unreliable evidence for a reduction in the severity of mucositis OR = 0.01 (95% CI: 0 to 0.03), amifostine provided minimal benefit in preventing mucositis RR = 0.95 (95% CI: 0.91 to 0.99), antibiotic paste or pastille demonstrated a moderate benefit in preventing mucositis RR = 0.87 (95% CI: 0.79 to 0.97), GM-CSF prevented mucositis RR = 0.51 (95% CI: 0.29 to 0.91), hydrolytic enzymes reduced the severity of mucositis RR = 0.49 (95% CI: 0.30 to 0.81), and ice chips prevented mucositis OR = 0.42 (95% CI: 0.19 to 0.93). Other interventions showing some benefit with only one study were: benzydamine, oral care protocols and povidone. The NNT to prevent one patient experiencing mucositis over a baseline incidence of 60% for amifostine is 33 (95% CI: 20 to 100), antibiotic paste or pastille 13 (95% CI: 8 to 50), GM-CSF 3 (95% CI: 2 to 20) and ice chips 5 (95% CI: 2 to 31). When the baseline incidence is 40%/90% the NNTs for amifostine are 50/20, for antibiotic paste or pastille 20/8, for GM-CSF 5/2 and for ice chips 6/10. The general reporting of RCTs was poor. However, the quality of the randomisation improved when the authors provided additional information.

REVIEWER'S CONCLUSIONS

Several of the interventions were found to have some benefit at preventing or reducing the severity of mucositis associated with cancer treatment. The strength of the evidence was variable and implications for practice include consideration that benefits may be specific for certain cancer types hat benefits may be specific for certain cancer types and treatment. There is a need for well designed and conducted trials with sufficient numbers of participants to perform subgroup analyses by type of disease and chemotherapeutic agent.

Interventions for replacing missing teeth: different types of dental implants

BACKGROUND

Dental implants are available in different materials, shapes and with different surface characteristics. In particular, numerous implant surface modifications have been developed for enhancing clinical performances.

OBJECTIVES

To test the null hypothesis of no difference in clinical performance between various root-formed osseointegrated dental implant types.

SEARCH STRATEGY

We searched the Cochrane Oral Health Group's Trials Register, The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE. Handsearching included several dental journals. We checked the bibliographies of relevant clinical trials and review articles for studies outside the handsearched journals. Two extensive personal libraries were consulted. We wrote to authors of the identified randomised controlled trials (RCTs), to more than 55 oral implant manufacturers; we used personal contacts and we asked on an internet discussion group in an attempt to identify unpublished or ongoing RCTs. No language restriction was applied. The last electronic search was conducted 21st March 2003.

SELECTION CRITERIA

All RCTs of oral implants comparing osseintegrated implants with different materials, shapes and surface properties having a follow up of at least 1 year.

DATA COLLECTION AND ANALYSIS

We carried out a quality assessment of the included RCTs and contacted the authors for missing information. We independently extracted the data in duplicate. We followed the Cochrane Oral Health Group's statistical guidelines.

MAIN RESULTS

Twenty-five different RCTs were identified. Ten of these RCTs, reporting results from a total of 428 patients, were suitable for inclusion in the review. Nine different implant types were compared with a follow up ranging from 1 to 3 years. All implants were made in commercially pure titanium and had different shapes and surface preparations. On a patient rather than per implant basis there were no statistically significant differences for failures, marginal bone level changes on intraoral radiographs and peri-implantitis between various implant systems.

REVIEWER'S CONCLUSIONS

There was no evidence that any of the implant systems evaluated was superior to the other. However, these findings are based on a few RCTs all having short follow-up periods and few participants. More RCTs should be conducted, with follow up of at least 5 years and including a sufficient number of patients to detect a true difference if any exists. Such trials should be reported according to the CONSORT guidelines (http://www.consort-statement.org/).

A randomized clinical trial to compare the effectiveness of canine lacebacks with reference to canine tip

AIM

To assess the effectiveness of canine lacebacks on the proclination of the upper incisors with reference to pre-treatment canine tip.

STUDY DESIGN

Randomized clinical trial.

SAMPLE

Patients receiving upper and lower fixed appliances attending the orthodontic departments of five orthodontic treatment providers. Sixteen patients received canine lacebacks as part of their treatment and 19 patients did not have canine lacebacks.

METHOD

Patients were randomly allocated to receive canine lacebacks or not receive canine lacebacks. Upper study models were collected at the initial archwire placement and then when the working 0.019 x 0.025-inch stainless steel archwire was placed. The start canine angulation, change in upper incisor proclination/overjet, and any mesial movement of the upper first permanent molars during levelling and aligning was measured with a reflex metrograph.

STATISTICS

The effect of the use of canine lacebacks on upper incisor proclination and mesial molar movement was assessed using Student t-tests. Regression analysis was used to evaluate any effect of the initial angulation of the canine.

RESULTS

A mean incisor retroclination of 0.5 mm was observed in the canine lacebacks compared with a mean proclination of 0.36 mm when canine lacebacks were not used (P = 0.025). There was no statistically significant difference between groups for mesial movement of upper first molars (P = 0.99). If the canine was more distally inclined at the start of treatment, the incisors was more likely to procline, regardless of whether or not canine lacebacks were used (P = 0.027).

CONCLUSIONS

The effect of canine lacebacks on preventing upper incisor proclination at the start of treatment is in the order of 1 mm and their effect on mesial molar movement is insignificant. Canines lacebacks have similar effects that are independent of pre-treatment canine angulation.

Orthodontic adhesives: a systematic review

OBJECTIVES

To evaluate which orthodontic adhesives (a). bond orthodontic brackets to teeth more reliably and (b). are more effective at preventing decalcification.

DATA SOURCES

The search strategy for the literature review was carried out according to the standard Cochrane systematic review methodology. The Cochrane Clinical Trials Register and the Cochrane Oral Health Group Specialized Register were searched for randomized clinical trials and controlled clinical trials. All volumes that had not already been assessed by the Oral Health Group in the European Journal of Orthodontics, American Journal of Orthodontics, Journals of Orthodontics, and Angle Orthodontist were hand-searched. Inclusion and exclusion criteria were applied when considering the studies to be included in this review.

DATA SELECTION

The primary outcome measure was the failure of the orthodontic adhesive. A secondary outcome of decalcification occurring around the orthodontic bracket was also recorded, if data were available.

DATA EXTRACTION

Two randomized clinical trials and one controlled clinical trial were identified that fulfilled all the inclusion and exclusion criteria. The trials compared: (a). light- and chemically-cured composite; (b). chemically-cured composite and conventional glass ionomer cement; and (c). chemically-cured composite and light-cured compomer.

DATA SYNTHESIS

Each paper was quality assessed by two people independently. A qualitative analysis of the trials in the review is presented. The data presentation, for the majority of the trials, precluded the use of suggested Cochrane Health Group statistical analysis.

CONCLUSIONS

It is difficult to draw any conclusions from this review; however, suggestions are made for methods of improving future research involving orthodontic adhesives.

A randomised controlled trial of the effectiveness of providing free fluoride toothpaste from the age of 12 months on reducing caries in 5-6 year old children

OBJECTIVE

To assess the impact of regularly supplying free fluoride toothpaste regularly to children, initially aged 12 months, and living in deprived areas of the north west of England on the level of caries in the deciduous dentition at 5-6 years of age. A further aim was to compare the effectiveness of a programme using a toothpaste containing 440 ppmF (Colgate 0-6 Gel) with one containing 1,450 ppmF (Colgate Great Regular Flavour) in reducing caries.

DESIGN

Randomised controlled parallel group clinical trial. Clinical data were collected from test and control groups when the children were 5-6 years old.

SETTING

A programme of posting toothpaste with dental health messages to the homes of children initially aged 12 months. Clinical examinations took place in primary schools.

PARTICIPANTS

7,422 children born in 3-month birth cohorts living in high caries areas in nine health districts in north west England. Within each district children were randomly assigned to test or control groups.

INTERVENTIONS

Toothpaste, containing either 440 ppmF or 1450 ppmF, and dental health literature posted at three monthly intervals to children in test groups until they were aged 5-6 years.

MAIN OUTCOME MEASURES

The dmft index, missing teeth and the prevalence of caries experience.

RESULTS

An analysis of 3,731 children who were examined and remained in the programme showed the mean dmft to be 2.15 for the group who had received 1,450 ppmF toothpaste and 2.49 for the 440 ppmF group. The mean dmft for the control group was 2.57. This 16% reduction between the 1,450 ppmF and control group was statistically significant (P<0.05). The difference between the 440 ppmF group and control was not significant. Further analyses to estimate the population effect of the programme also confirmed this relationship.

CONCLUSION

This study demonstrates that a programme distributing free toothpaste containing 1,450 ppmF provides a significant clinical benefit for high caries risk children living in deprived, non-fluoridated districts.

Prevention of oral mucositis and oral candidiasis for patients with cancer treated with chemotherapy: cochrane systematic review

The objectives of this study were to determine whether oral prophylactic agents are superior to placebo or no treatment on the incidence of oral mucositis and oral candidiasis for patients with cancer. A Cochrane systematic review was conducted of randomized trials of oral (and topical) prophylactic agents for mucositis and oral candidiasis, anywhere in the world, among patients with cancer (excluding head and neck) who were receiving chemotherapy. Eleven studies were included in the meta-analysis for mucositis. Of the six prophylactic agents used for mucositis, only one--ice chips--was effective (relative risk 0.57, 95% CI 0.43 to 0.77). Fifteen studies were included in the meta-analysis for oral candidiasis. There is evidence that antifungal agents that are partially or fully absorbed from the gastrointestinal tract prevent oral candidiasis and that the partially absorbed agents may be more effective than the fully absorbed agents. The RR for partially absorbed agents was 0.13 (95% CI 0.06 to 0.27). In conclusion, there is weak and unreliable evidence that ice chips prevent mucositis. There is evidence that prophylactic use of antifungal agents, which are absorbed or partially absorbed from the gastrointestinal tract, reduce the clinical signs of oral candidiasis.

Association between female hormonal factors and oro-facial pain: study in the community

The aim of this study was to determine the relationship between the prevalence of oro-facial pain (OFP) in the population and female hormonal factors. The cross-sectional population study was conducted in a general medical practice in the north-west of England. A random sample of 4000 adults aged 18-65 years were mailed questionnaires, of whom 2504 responded (adjusted participation rate 74%). Of these 1245 women provided information on both OFP and hormonal factors. For pre- or peri-menopausal women, there was no relationship between oral contraceptive use and OFP (age-adjusted relative risk (RR) 1.10; 95% confidence interval (CI) 0.81, 1.45), whilst a high score on a pre-menstrual symptom questionnaire was associated with an age-adjusted RR of 1.87 (95% CI 1.36, 2.57). Those who reported menstruating for 6 days or longer had moderate increase in risk of OFP (age-adjusted RR 1.39; 95% CI 1.01, 1.91). In post-menopausal women, there was a moderate relationship between hormone replacement therapy use and OFP (age-adjusted RR 1.46; 95% CI 1.02, 2.08). For women overall, there was an increased risk of OFP in those who reported ever having had painful periods (age-adjusted RR 1.47; 95% CI 1.20, 1.80), but no association was found with the number of children. This cross-sectional community-based study adds important information on the relationship between female hormonal factors and OFP. Women who report OFP are more likely to report symptoms associated with menstruation. This may indicate either the importance of hormones per se or identify a group of women who are more likely to report symptoms in general.

Routine panoramic radiography of new adult patients in general dental practice: relevance of diagnostic yield to treatment and identification of radiographic selection criteria

OBJECTIVES

We sought to measure the diagnostic yield of relevance to treatment on routine panoramic radiographs taken of new adult (ie, 18 years and over) patients in general dental practice.

STUDY DESIGN

Routine panoramic radiographs (n = 1817) obtained from general dental practice were assessed and radiologic yield recorded using consensus viewing by 2 dental radiologists. A modified diagnostic yield of relevance to treatment for each radiograph was calculated by omission of findings that would have been identified on bilateral posterior bitewing radiographs and of radiologic findings of no relevance to treatment. Stepwise logistic regression analysis was used in attempt to identify clinical indicators of a high diagnostic yield of relevance to treatment.

RESULTS

The diagnostic yield of relevance to treatment was zero for the majority (56%) of patients. This figure rose to 71% when the symptom-free patients were considered. Five clinical indicators for panoramic radiography were identified, as follows: clinical suspicion of teeth with periapical pathologic conditions, presence of partially erupted teeth, clinically evident caries lesions, swelling, and clinically suspected unerupted teeth.

CONCLUSION

Routine panoramic radiography of adult dental patients is not supported by the results of this study. The use of clinical indicators to select patients may help to improve diagnostic yield.

Sex hormonal factors and chronic widespread pain: a population study among women

OBJECTIVE

The observation of higher rates of chronic widespread pain, the cardinal feature of fibromyalgia, in women has led to hypotheses about the role of sex hormonal factors in the aetiology of symptoms. There is little available evidence from epidemiological studies on their importance or role.

METHODS

A population postal survey was carried out involving 1178 female participants living in south-east Cheshire in the north-west of England.

RESULTS

Amongst pre- and peri-menopausal women, the risk of chronic widespread pain was unrelated either to the length of the menstrual cycle or the usual length of period reported by participants. Risk was similar in current users and non-users of the oral contraceptive pill, and amongst users there was no relationship with duration of use. However, the reporting of chronic widespread pain showed a relationship with total score on a premenstrual symptom questionnaire. However, this relationship was explained by pain symptoms. Amongst post-menopausal women, reporting chronic widespread pain was not related to age at menopause. An increased (but non-significant) risk of chronic widespread pain was associated with current hormone replacement therapy (HRT), which may be a consequence of HRT being prescribed for menopausal symptoms.

CONCLUSION

This study, conducted on a large unselected population, has not demonstrated an association between sex hormonal factors and chronic widespread pain.

Screening panoramic radiography of new adult patients: diagnostic yield when combined with bitewing radiography and identification of selection criteria

OBJECTIVES

To measure the radiological diagnostic yield on screening panoramic radiographs taken of new adult patients and to identify selection criteria for panoramic radiography of new adult patients.

DESIGN

Survey of 1,817 consecutive panoramic radiographs taken as 'routine' on new patients with statistical analysis of clinical and radiological findings.

SETTING

All radiographs were obtained from 41 general dental practitioners (GDPs). The GDPs provided the clinical information about the patient obtained by history and examination. Collection of material occurred in 1998/1999.

MATERIALS AND METHODS

Two dental radiologists recorded the radiological findings on each of 1,817 panoramic radiographs by consensus. Those findings that would have been identified from bilateral posterior bitewing radiographs of each patient were then excluded to give modified figures for radiological findings.

MAIN OUTCOME MEASURES

Indices of diagnostic yield were devised and calculated for each radiograph from the data on radiological findings. Total diagnostic yield (DY) and modified diagnostic yield (MDY), after exclusion of findings identifiable on bitewing radiographs, were both calculated. Clinical indicators of a high MDY were identified using stepwise multiple regression analysis.

RESULTS

MDY was 0 for 17% of the radiographs (all patients) and 23% of the radiographs when the asymptomatic group were considered. The clinical variables for which the significance was high (p < 0.001) were: increasing number of teeth with clinical suspicion of periapical pathology, presence of partially erupted teeth, increasing number of clinically evident carious lesions, partially dentate status and presence of crowns.

CONCLUSION

Taking posterior bitewing radiographs of new adult patients would reduce the diagnostic yield identified solely by panoramic radiography. Using clinical factors derived from the history and examination as radiographic selection criteria modestly improves the odds of achieving a high diagnostic yield from panoramic radiography.

A randomized clinical trial to compare three methods of orthodontic space closure

AIM

To compare the rates of orthodontic space closure for: Active ligatures, polyurethane powerchain (Rocky Mountain Orthodontics, RMO Europe, Parc d'Innovation, Rue Geiler de Kaysersberg, 67400 Illkirch-Graffenstaden, Strasbourg, France) and nickel titanium springs.

SAMPLE

Patients entering the space closure phase of fixed orthodontic treatment attending six orthodontic providers. Twelve patients received active ligatures (48 quadrants), 10 patients received powerchain (40 quadrants) and 11 patients, nickel-titanium springs (44 quadrants).

METHOD

Patients were randomly allocated for treatment with active ligatures, powerchain or nickel titanium springs. Upper and lower study models were collected at the start of space closure (T(o)) and 4 months later (T(1)). We recorded whether the patient wore Class II or Class III elastics. Space present in all four quadrants was measured, by a calibrated examiner, using Vernier callipers at T(o) and T(1.) The rate of space closure, in millimetres per month (4 weeks) and a 4-monthly rate, was then calculated. Examiner reliability was assessed at least 2 weeks later.

RESULTS

Mean rates of space closure were 0.35 mm/month for active ligatures, 0.58 mm/month for powerchain, and 0.81 mm/month for NiTi springs. No statistically significant differences were found between any methods with the exception of NiTi springs showing more rapid space closure than active ligatures (P < 0.05). There was no effect of inter-arch elastics on rate of space closure.

CONCLUSIONS

NiTi springs gave the most rapid rate of space closure and may be considered the treatment of choice. However, powerchain provides a cheaper treatment option that is as effective. The use of inter-arch elastics does not appear to influence rate of space closure.