An in vitro comparison of pH changes in root dentine following canal dressing with calcium hydroxide points and a conventional calcium hydroxide paste

AIM

This study aimed to measure and compare pH changes at apical and cervical sites on the external root surface of extracted teeth dressed with calcium hydroxide in two different formulations.

METHODOLOGY

Root canals of 45 single-rooted extracted human teeth were accessed and shaped using a step-down technique with rotary instrumentation. Standard cavities were prepared on the external root surface at specific apical and cervical sites. The teeth were randomly allocated to three groups. Teeth in group A were dressed with calcium hydroxide points, those in group B were dressed with an aqueous calcium hydroxide paste and teeth in group C were left unfilled. Following storage in humid conditions, the pH of the dentine at apical and cervical sites was measured at baseline and then at 24 h, 72 h, 1 week, 10 days, 2 weeks and 3 weeks.

RESULTS

The pH of the root dentine at both apical and cervical sites was significantly greater (P < 0.001) in teeth dressed with aqueous calcium hydroxide paste compared with those dressed with calcium hydroxide points, when averaged out across all time periods. For all groups, there was a significant difference between the mean apical and cervical pH values for each tooth with lower values for the apical sites (P < 0.001).

CONCLUSION

The results of this study indicate that an aqueous calcium hydroxide paste was more effective than calcium hydroxide points at raising the pH on the external root surface of extracted teeth.

Interventions for replacing missing teeth: preprosthetic surgery versus dental implants

BACKGROUND

Preprosthetic surgery refers to the surgical procedures that can modify the oral anatomy to facilitate the retention of conventional dentures. Osseointegrated implants offer an alternative treatment to improve denture retention. A denture may be connected by special attachments to implants placed into the jaw.

OBJECTIVES

To test the null hypothesis of no difference in the success (patient satisfaction and morbidity) and cost effectiveness between conventional prostheses that require preprosthetic surgery (PPS) and implant retained prostheses (IRO) that do not require preprosthetic surgery, against the alternative hypothesis of a difference.

SEARCH STRATEGY

The Cochrane Oral Health Group (OHG) Specialised Register (May 2002), the Cochrane Controlled Trials Register (Issue 2, 2002), MEDLINE and EMBASE (May 2002) were searched. In addition, 55 implant companies were contacted and the bibliographies of review articles were checked for studies outside the hand searched journals and personal references were searched.

SELECTION CRITERIA

Randomised controlled trials comparing preprosthetic surgery and implant retained dentures for improving denture retention.

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

One study, containing 60 participants, reported in four articles was identified for inclusion in this review. No studies were excluded. There was a statistically significant difference between mean patient satisfaction scores with patients in the IRO group being more satisfied in general at both year one (WMD = -0.66(95% CI; -1.28 to -0.04)) and five years (WMD = -0.90(95%CI; -1.74 to -0.06). Altered sensation of the lower lip and chin was measured at one year and five years. There was no statistically significant difference at either time point and no patients had altered sensation at five years.

REVIEWER'S CONCLUSIONS

There is weak evidence from the results of one randomised controlled trial including 60 subjects that patients are generally less satisfied with preprosthetic surgery and a conventional denture than with an implant retained denture. There is a need for more well designed trials comparing the success and cost-effectiveness of preprosthetic surgery and implant supported dentures. Such trials should be reported according to the CONSORT guidelines (http://www.consort-statement.org/). However, since preprosthetic surgery is considered to be an obsolete treatment nowadays, almost completely replaced by dental implants, it may be that new RCTs on this topic will not be designed.

Interventions for preventing oral candidiasis 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 and treat them. One of these side effects is oral candidiasis.

OBJECTIVES

To assess the effectiveness of interventions (which may include placebo or no treatment) for the prevention of oral candidiasis for patients with cancer receiving chemotherapy and or radiotherapy.

SEARCH STRATEGY

Electronic databases : Cochrane Oral Health Group Specialised Register, CCTR, MEDLINE and EMBASE were searched. Date of the most recent searches May 2001 (CCTR 2001, issue 3).

SELECTION CRITERIA

Trials were selected if they met the following criteria: design - random allocation of participants; participants - anyone receiving chemotherapy or radiotherapy treatment for cancer; interventions - agents prescribed to prevent oral candidiasis; primary outcome - prevention of oral candidiasis.

DATA COLLECTION AND ANALYSIS

Data were recorded on the following secondary outcomes if present: relief of pain, amount of analgesia, relief of dysphagia, incidence of systemic infection, duration of stay in hospital (days), cost of oral care, patient quality of life, death, use of empirical antifungal treatment, toxicity and compliance. Information regarding methods, participants, interventions, outcome measures and results were independently extracted, in duplicate, by two reviewers (HW & JC). The Cochrane Oral Health Group statistical guidelines were followed and relative risk values calculated using random effects models where significant heterogeneity was detected (P<0.1). Potential sources of heterogeneity were examined in random effects meta-regression analyses.

MAIN RESULTS

Twenty-seven trials involving 4,137 patients satisfied the inclusion criteria. Drugs absorbed and partially absorbed from the GI tract were found to prevent oral candidiasis when compared to a placebo, or a no treatment control group, with RR for absorbed drugs =0.45 (95%CI 0.31 to 0.64). For absorbed drugs in populations with an incidence of 20% (mid range of results in control groups), this implies a NNT of 9 (95%CI 7 to 13) patients need to be treated to avoid one patient getting oral candidiasis. There was no significant benefit for drugs not absorbed from the GI tract.

REVIEWER'S CONCLUSIONS

There is strong evidence, from randomised controlled trials, that drugs absorbed or partially absorbed from the GI tract prevent oral candidiasis in patient receiving treatment for cancer. There is also evidence that these drugs are significantly better at preventing oral candidiasis than drugs not absorbed from the GI.

Interventions for treating oral mucositis for patients with cancer receiving treatment

BACKGROUND

Treatment of cancer is increasingly effective but associated with short and long-term side effects. Oral side effects, including oral mucositis (ulceration), remain a major source of illness despite the use of a variety of agents to treat them.

OBJECTIVES

To assess the effectiveness of interventions for treating oral mucositis or its associated pain in patients with cancer receiving chemotherapy and/or radiotherapy.

SEARCH STRATEGY

Computerised searches of Cochrane Oral Health Group Specialised Register, CCTR, MEDLINE and EMBASE were undertaken. Reference lists from relevant articles were searched. Authors of eligible trials were contacted to identify trials and obtain additional information. Date of most recent searches: May 2001 (CCTR 2001, issue 3)

SELECTION CRITERIA

All randomised controlled trials comparing agents prescribed to treat oral mucositis in people receiving chemotherapy and/or radiotherapy. Outcomes were oral mucositis, oral pain, dysphagia, systemic infection, amount of analgesia, length of hospitalisation, cost and quality of life.

DATA COLLECTION AND ANALYSIS

Data were independently extracted, in duplicate, by two reviewers. Authors were contacted for details of randomisation, blindness and withdrawals. Quality assessment was carried out on these three criteria. Cochrane Oral Health Group statistical guidelines were followed and relative risk values calculated using fixed effects models as no significant heterogeneity was detected (P>0.1).

MAIN RESULTS

Fifteen trials involving 876 patients satisfied the inclusion criteria. Two agents, each in single trials, were found to be effective for improving (allopurinol RR=0.63 95%CI 0.42 to 0.96) or eradicating mucositis (allopurinol RR=0.59 95%CI 0.42 to 0.84; vitamin E RR=0.38 95%CI 0.14 to 0.97). The following agents were not found to be effective: benzydamine HCl, sucralfate, tetrachlorodecaoxide, chlorhexidine and "magic" (lidocaine solution, diphenhydramine hydrochloride and aluminum hydroxide suspension). Three trials compared patient controlled analgesia (PCA) to the continuous infusion method for controlling pain. There was no evidence of a difference, however, less opiate was used per hour for PCA. One trial demonstrated that pharmacokinetically based analgesia (PKPCA) reduced pain compared with PCA, however more opiate was used with PKCA.

REVIEWER'S CONCLUSIONS

There is weak and unreliable evidence that allopurinol mouthwash and vitamin E improves or eradicates mucositis. There is no evidence that patient controlled analgesia (PCA) is better than continuous infusion method for controlling pain, however, less opiate was used per hour for PCA. Further, well designed, placebo-controlled trials assessing the effectiveness of allopurinol mouthwash, vitamin E and new interventions for treating mucositis are needed.

Interventions for replacing missing teeth: maintaining and re-establishing healthy tissues around dental implants

BACKGROUND

To maintain healthy tissues around oral implants it is important to institute an effective preventive regimen (supportive therapy) and when a pathologic condition of the tissue around implants is diagnosed, an intervention should be initiated as soon as possible. Different maintenance regimens and treatment strategies for failing implants have been suggested, however it is unclear which are the most effective.

OBJECTIVES

To test the null hypothesis of no difference between different interventions for maintaining or re-establishing healthy tissues around dental implants.

SEARCH STRATEGY

The Cochrane Oral Health Group Specialised Register, The Cochrane Controlled Trials Register, MEDLINE and EMBASE were searched. Hand searching included several dental journals. In addition, authors of all identified trials, fifty-five oral implant manufacturers and two extensive personal libraries (ME and AJ) were consulted.

SELECTION CRITERIA

All randomised controlled trials of oral implants comparing agents or interventions for maintaining or re-establishing healthy tissues around dental implants.

DATA COLLECTION AND ANALYSIS

Data were independently extracted, in duplicate, by two reviewers (ME & HW). 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.

MAIN RESULTS

Nine RCTs were identified. Five of these trials, which reported results from a total of 127 patients, were suitable for inclusion in the review.

REVIEWER'S CONCLUSIONS

There is only a little reliable evidence for which are the most effective interventions for maintaining health around peri-implant tissues. There was no evidence that the use of powered or sonic toothbrushes was superior to manual toothbrushing. There is a weak evidence that Listerine mouthwash, used twice a day for 30 seconds, as adjunct to routine oral hygiene is effective in reducing plaque formation and marginal bleeding around implants. There was no evidence that phosphoric etching gel offered any clinical advantage over mechanical debridement. These findings are based on RCTs having short follow-up periods and few subjects. There is not any reliable evidence for the most effective regimens for long-term maintenance. For the treatment of failing implants (peri-implantitis) there is not any reliable evidence for preferring one therapeutic regimen over another. More RCTs should be conducted in this area. In particular, there is a definite need for trials investigating which is the most effective approach for the treatment of peri-implantitis and for trials with longer follow-up for maintenance. Such trials should be reported according the CONSORT guidelines (http://www.consort-statement.org/).

Interventions for treating oral candidiasis for patients with cancer receiving treatment

BACKGROUND

Treatment of cancer is increasingly effective but is associated with short and long-term side effects. Oral side effects, including oral candidiasis, remain a major source of illness despite the use of a variety of agents to treat them.

OBJECTIVES

To assess the effectiveness of interventions for the treatment of oral candidiasis for patients with cancer receiving chemotherapy and or radiotherapy.

SEARCH STRATEGY

Computerised searches of Cochrane Oral Health Group Specialised Register, CCTR, MEDLINE and EMBASE were undertaken. Reference lists from relevant articles were searched and the authors of eligible trials were contacted to identify trials and obtain additional information. Date of the most recent searches May 2001: (CCTR 2001, issue 3)

SELECTION CRITERIA

All randomised controlled trials comparing agents prescribed to treat oral candidiasis in people receiving chemotherapy or radiotherapy for cancer. The outcomes were eradication of oral candidiasis, dysphagia, systemic infection, amount of analgesia, length of hospitalisation, cost and patient quality of life.

DATA COLLECTION AND ANALYSIS

Data 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 where significant heterogeneity was detected (P<0.1).

MAIN RESULTS

Eight trials involving 418 patients, satisfied the inclusion criteria and are included in this review. Only two agents, each in single trials, were found to be effective for eradicating oral candidiasis. A drug absorbed from the gastrointestinal tract, ketoconazole, was more beneficial than placebo in eradicating oral candidiasis (RR=0.35 95%CI 0.20 to 0.61) and clotrimazole, at a higher dose of 50mg was more effective than a lower 10mg dose in eradicating oral candidiasis, when assessed mycologically (RR=0.47 95%CI 0.25 to 0.89). Another trial demonstrated no difference between a 10mg dose of the partially absorbed drug, clotrimazole, and placebo. No differences were found when comparing different absorbed drugs; and comparing absorbed drugs with drugs which are not absorbed.

REVIEWER'S CONCLUSIONS

There is weak and unreliable evidence that the absorbed drug, ketoconazole, may eradicate oral candidiasis and that a higher dose of the partially absorbed drug, clotrimazole, may give greater benefit than a lower 10mg dose, however, researchers may wish to prevent rather than treat oral candidiasis. Further well designed, placebo-controlled trials assessing the effectiveness of old and new interventions for treating oral candidiasis are needed.

Interventions for replacing missing teeth: hyperbaric oxygen therapy for irradiated patients who require dental implants

BACKGROUND

Dental implants offer one way to replace missing teeth and associated tissues. Patients who have undergone radiotherapy and those that have also undergone surgery for cancer may benefit particularly from reconstruction with implants. Hyperbaric oxygen therapy (HBO) has been advocated to improve the success of implant treatment in patients who have undergone radiotherapy but this remains a controversial issue.

OBJECTIVES

This review aims to compare success, morbidity, patient satisfaction and cost effectiveness of dental implant treatment carried out with and without HBO in irradiated patients.

SEARCH STRATEGY

The Cochrane Oral Health Group Specialised Register, the Cochrane Controlled Trials Register, 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. We also wrote to implant manufacturers and experts in the field.

SELECTION CRITERIA

Randomised controlled trials of HBO therapy for irradiated patients requiring dental implants.

DATA COLLECTION AND ANALYSIS

No randomised trials were identified.

MAIN RESULTS

No data were available.

REVIEWER'S CONCLUSIONS

Clinicians ought to make patients aware of the lack of reliable clinical evidence for or against the clinical effectiveness of HBO in irradiated patients requiring dental implants. There is a definite need for RCTs to ascertain the effectiveness of HBO in irradiated patients requiring dental implants. These trials ought to be of a high quality and reported as recommended by the CONSORT statement (http://www.consort-statement.org/). Each clinical centre may have limited numbers of patients and it is likely that trials will need to be multi-centred.

Factors associated with the temporomandibular disorder, pain dysfunction syndrome (PDS): Manchester case-control study

OBJECTIVES

To determine the individual and combined effects of potential risk factors in relation to the temporomandibular disorder, Pain Dysfunction Syndrome (PDS).

DESIGN

Case-control study.

MATERIAL AND METHODS

Cases were new referrals to the temporomandibular disorder clinic of the University Dental Hospital of Manchester, diagnosed with PDS. Controls were randomly selected from 24 dental practices. Using a postal questionnaire information was collected on socio-demographic, local mechanical, psychological factors, co-morbidities and illness behaviour. The adjusted participation rate was similar in cases and controls (64%), and 131 cases and 196 controls finally participated in the study.

RESULTS

Compared with the controls, the cases were more likely to report that their teeth felt as though they did not fit together properly [odds ratio (OR) 8, 95% Confidence Interval (CI) 6-13] and report history of facial trauma (OR 3, 95% CI 2-6). Both diurnal and nocturnal grinding were significantly associated with PDS, and individuals who reported grinding their teeth both during the day and at night had a risk of 6; 95% CI 3-13 for PDS compared with those who did not. A history of orthodontic treatment, having any dentures, having missing teeth, use of chewing gum or biting the fingernails did not show any relationship with PDS. People who took medication for the bowels had a higher risk of PDS (OR 2, 95% CI 1-4). Participants with frequent headaches had a threefold increase in risk of having PDS (OR 3, 95% CI 2-5) while having pain in parts of the body other than the head was associated with an OR of 3 (95% CI 2-5). An increased propensity to have PDS was seen in those individuals with higher levels of psychological distress (OR 3; 95% CI 1-4 in the highest category, test for trend P < 0.001) and sleep disturbance (OR 5; 95% CI 2-94 in the highest category, test for trend P < 0.001). Aspects of illness behaviour, such as disease conviction (OR 4; 95% CI 2-9 in the highest category) and perception of illness (0.3; 95% CI 0.2-0.5) were associated with PDS. The result for the denial scale became statistically significant after adjustment for age and gender (2; 95% CI 1-3).

CONCLUSIONS

The current case-control study provides complementary epidemiological information on oro-facial pain (OFP) and supports a multifactorial aetiology of PDS, with factors from many domains, including local mechanical factors, psychological and co-morbidities. People with PDS were characterized by frequent headaches, history of facial trauma, teeth grinding, sleep problems, pain elsewhere in the body and high levels of psychological distress. From the results of current study and available evidence it seems inappropriate to consider PDS in isolation and future research should adopt a multidisciplinary approach to OFP.

Quality assessment of randomized controlled trials of oral implants

The aim of this study was to assess the quality of randomized controlled trials (RCTs) concerned with the effectiveness of oral implants and to create a trial register. A multilayered search strategy was used to identify all RCTs published by the end of 1999 in any language. The Cochrane Oral Health Group specialist register, PubMed, and personal libraries were searched. Seventy-four RCTs were identified. Forty-three articles, not presenting the same patient material, were independently assessed by 3 researchers using a specially designed form. A statistician assessed all trials for the appropriateness of statistics. The quality of each study was assessed on 7 items, including 3 key domains. Randomization and concealment allocation procedures were not described in 30 articles (70%). Reasons for withdrawals were not given in 10 reports (23%). No attempt at blinding was reported in 31 studies (72%). The quality of RCTs of oral implants is generally poor and needs to be improved.

A cluster randomized controlled trial testing the effectiveness of a school-based dental health education program for adolescents

OBJECTIVES

This trial investigated the value of a school-based dental health education program in terms of changes in knowledge, reported behavior, and plaque scores.

METHODS

A total of 2,678 pupils with a mean age of 12.1 years attending 28 schools participated in a school-based dental health education program. The study used a cluster randomized controlled study design. The health service administrators stipulated that all participants receive the intervention; to meet this requirement, a rolling program of two six-month periods was utilized. During the first six months, half the adolescents received the intervention program, the other half acting as controls. Throughout a further six-month period, all participants received the intervention program. This research design allowed comparisons between participants receiving the program for six and 12 months. At baseline, six, and 12 months, a random subsample of 40 children in each participating school had their plaque scores recorded and a questionnaire was used to record their knowledge of dental health and reported dental behavior.

RESULTS

The analysis used the subjects clustered within the schools, which were the units of randomization. The intervention program produced statistically significant improvements (P < .001) in knowledge about periodontal disease and the frequency of sugar intake and dental caries in both assessment time periods. The reported frequency of brushing did not change, but the group who had received 12 months of the intervention were more likely (P < .05) to brush for over a minute. At six months the early intervention group had a statistically significant, 13 percent reduction in the mean proportion of sites with plaque compared with the late intervention group (P = .043). This difference was sustained at 12 months (P = .037).

CONCLUSION

This cluster randomized control trial demonstrated that the intervention program resulted in an improvement in knowledge of dental disease and an increase in the reported duration of brushing. These improvements were accompanied by a significant improvement in oral hygiene and a reported reduction in gingival bleeding.

In search of truth: the role of systematic reviews and meta-analyses for assessing the effectiveness of rehabilitation with oral implants

BACKGROUND

It is difficult to determine the effectiveness or potential harm of dental therapies. Thus, any tools able to condense reliable scientific information would be of benefit.

PURPOSE

To discuss methods for the assessment of the scientific literature and, in particular, of systematic reviews for evaluating the effectiveness of oral implant rehabilitation procedures.

MATERIALS AND METHODS

Various study designs and methods to identify scientific evidence are described, discussed, and ranked. Issues on how to critically appraise randomized controlled clinical trials (RCTs) and systematic reviews are presented.

RESULTS

Properly conducted RCTs and structured critical systematic reviews are the gold standard of clinical research for assessing whether a therapeutic intervention is effective. In the field of oral implantology, there is an urgent need to implement more RCTs and to summarize their results in systematic reviews.

CONCLUSIONS

Searching of the truth requires training and critical skill. Dentists should be trained on how to integrate their clinical experience with evidence-based research and on how to discriminate between clinically useful scientific information and less useful research.

Systematic review of population-based epidemiological studies of oro-facial pain

OBJECTIVES

To conduct a systematic review of epidemiological literature in order to determine the prevalence and associated risk factors of oro-facial pain.

DATA

Population based observational studies (cohorts, cross-sectional and case-control studies) of oro-facial pain, published in the English language, prior to 1999 were included.

SOURCES

Electronic databases (Medline, Embase, Cinahl, BIDS and Health CD) were searched. Reference lists of relevant articles were examined, and the journals "Pain" and "Community Dentistry and Oral Epidemiology" were handsearched for the years 1994-1998.

RESULTS

The results of the search strategy were screened for relevance. A standardised checklist was used to assess the methodological quality of each study by two reviewers before an attempt was made to summarise the results. The median quality score was 70% of the maximum attainable score. Due to methodological issues, it was not possible to pool the data on the prevalence of oro-facial pain. Age, gender and psychological factors were found to be associated with OFP, however there was not enough information on other factors such as local mechanical and co-morbidities to draw any reliable conclusions. None of the factors fully fulfilled criteria for causality.

CONCLUSIONS

There is a need for good quality epidemiological studies of oro-facial pain in the general population. To enable comprehensive examination of the aetiology of oro-facial pain, it is necessary to address a broad range of factors including demography and life-style, local mechanical factors, medical history and psychological factors. Future studies should recruit adequately sized samples for precise determination of the prevalence and detection of important associated factors. Data on potential confounders and effect modifiers should also be collected and adjusted for in the statistical analysis.

A cluster randomized controlled trial of a dental health education program for 10-year-old children

OBJECTIVE

Using a cluster randomized trial, this study tested the effectiveness of a dental health education program designed to improve the oral hygiene and dental knowledge of 10-year-old children.

METHODS

Thirty-two primary schools in the northwest of England participated. After a baseline assessment of plaque and the completion of a dental knowledge questionnaire by the children, the schools were allocated randomly to active or control groups. Children in schools allocated to the active group received the dental health program, which consisted of four one-hour lessons. After four months the children were examined clinically and scored for plaque, and a second questionnaire was administered. The schools in the control group were then allocated randomly to receive the program or not over the following three months, the program being withdrawn from the schools who initially received it. A further assessment of plaque was made and a questionnaire administered seven months after the baseline of the study.

RESULTS

The active groups had 20 percent and 17 percent lower mean plaque scores than the control group at four and seven months (P < .001). The children's knowledge of which type of toothbrush should be used and the role of disclosing tablets improved in the initial test group when compared with the control group and this was retained over the second part of the study.

CONCLUSION

The children receiving the program had significantly lower mean plaque scores and greater knowledge about toothbrushes and disclosing tablets than the control children who had not received the program.

The use of fibre-optic transillumination in general dental practice

OBJECTIVE

To assess the use of fibre-optic transillumination (FOTI) as a diagnostic tool in general dental practice.

DESIGN

A cross-over quantitative study for the diagnosis of approximal carious lesions by two clinical methods with a qualitative component.

SUBJECTS AND METHODS

Seven GDPs were trained to use FOTI as an adjunct to their usual clinical examination to diagnose approximal caries. After 12 weeks of use in their practices four of the GDPs took part in two assessment sessions, set a week apart, using 29 volunteer patients. Each patient was examined on two separate occasions by each GDP using either their standard clinical examination technique alone or supplemented by FOTI examination. The order of the techniques was randomised. Radiographs of each patient were also examined separately. An experienced FOTI user also examined the patients to provide a benchmark. From standard charts the number of enamel and dentinal lesions on approximal surfaces was summed and comparisons made between the techniques. Six GDPs took part in one-to-one interviews.

MAIN OUTCOME MEASURES

Mean numbers ofcarious lesions recorded by each clinician using each technique.

RESULTS

There was a trend for all GDPs to find more enamel and dentinal lesions using FOTI, than with their standard clinical examination with or without radiographs. All GDPs found the FOTI technique a useful adjunct. They used FOTI in different ways and found a variety of uses for it other than caries diagnosis.

CONCLUSIONS

The

An investigation into the value and relevance of oral health promotion leaflets for young adolescents

OBJECTIVES

To determine if oral health promotion leaflets of a novel design and content would be read by, acceptable to and influence 11-12-year-old children.

METHOD

Three related leaflets were incorporated into a dental health education programme aimed at 11-12-year-old children. The leaflets were designed specifically, following consultation with focus groups. They had a romantic story line and emphasised the immediate gains from good dental health, relevant to this age group. A random sample of pupils completed a written questionnaire on the impact of the leaflets at the end of the one-year programme. These sample pupils underwent a clinical examination to measure plaque before and after the programme.

RESULTS

2,678 pupils with a mean age of 12.1 years participated in the programme. 895 were randomly selected to join the assessment study. Most pupils 81%, (725) reported they had read the leaflets; 61% (442) finding them enjoyable to read, 51% (370) attractive to look at and 71% (515) finding the story lines interesting. However, girls appreciated the leaflets more than the boys. There was some suggestion that the leaflets played a positive role in the overall success of the programme in that most pupils 83% (602) reported they thought more about caring for their teeth after reading the leaflets and 58% reported their brushing frequency had increased.

CONCLUSION

The results indicate that for adolescents, leaflets which feature interpersonal relationships are well accepted and can stimulate better oral health behaviour.

Evaluation of computer aided learning in developing clinical decision-making skills

AIM

The aim of this study was to determine whether an educational intervention delivered by a computer aided learning package improved the sensitivity and specificity of dentists' restorative treatment decisions.

METHOD

The study was a randomised controlled study using a Solomon three-group design. Ninety-five dentists were randomly allocated to the three study groups. One group of dentists read the radiographs pre and post an educational intervention, a second group read the radiographs once, after the intervention, and a third group read the radiographs twice, but received no intervention. On each occasion the dentists read 24 surfaces on each of 15 radiographs and made 360 decisions on how certain they were about restoring the tooth surface. Comparisons of mean sensitivity, specificity and areas under ROC curves were made within and between the study groups. Kappa values were used to assess changes in the level of agreement between dentists.

RESULTS

There were no significant changes in sensitivity, specificity or area under ROC curves caused by the intervention. There was no evidence that the level of agreement between the dentists improved after the intervention.

CONCLUSION

A computer aided learning package had no effect on dentists' treatment decision-making behaviour.

Screening panoramic radiology of adults in general dental practice: radiological findings

AIM

To identify the radiological findings from routine screening panoramic radiographs taken of adult (> or = 18 years) patients in general dental practice.

METHOD

Forty-one general dental practitioners (GDPs) who routinely took panoramic radiographs of all new adult patients were recruited. In total, they submitted 1,818 panoramic radiographs of consecutive patients along with basic patient information, radiological reports and treatment plans. The radiographs were also reported by 'experts' (consensus of two dental radiologists). Radiological findings were recorded from the GDP assessments (dentist RY), the experts (expert RY), after exclusion of findings that would have been seen on posterior bitewing radiographs (MRY) and after exclusion of findings of no relevance to treatment (MRYT).

RESULTS

There was no significant difference in age profile between the study sample and Dental Practice Board population figures (P = 0.26). No radiographs other than the panoramic radiograph had been taken for 57.1% of patients. For the GDP assessments, only 4.6% of patients had radiographs with no radiological findings, while for the experts this proportion was 3.1%. With the exception of the assessment of periodontal bone loss, the experts diagnosed significantly greater proportions of cases as having positive radiological findings. Agreement between dentist and expert assessments varied greatly. When findings from bitewing radiographs were excluded, no radiological findings were recorded on the radiographs of 17.2% of patients. When proposed treatment plans were taken into account, the majority of patients' radiographs (56.3%) had no radiological findings of relevance to treatment.

CONCLUSIONS

The choice of radiographic examination for the majority of patients in the study did not follow current guidelines. Dentists diagnosed fewer abnormalities than did experts. While many radiological findings are revealed by panoramic radiography, these may either duplicate information from bitewing radiographs or are often of no significance to treatment planning. This study did not provide evidence to support the practice of routine panoramic radiography of all new adult patients.

Guided tissue regeneration for periodontal infra-bony defects

BACKGROUND

Conventional treatment of destructive periodontal (gum) disease arrests the disease but does not regain the bone support or connective tissue lost in the disease process. Guided tissue regeneration (GTR) is a surgical procedure that aims to regenerate the periodontal tissues when the disease is advanced and could overcome some of the limitations of conventional therapy.

OBJECTIVES

To assess the efficacy of GTR in the treatment of periodontal infra-bony defects measured against the current standard of surgical periodontal treatment, open flap debridement.

SEARCH STRATEGY

We conducted an electronic search of the Cochrane Oral Health Group specialised trials register and MEDLINE up to October 2000. Hand searching included Journal of Periodontology, Journal of Clinical Periodontology, Journal of Periodontal Research and bibliographies of all relevant papers and review articles up to October 2000. In addition, we contacted experts/groups/companies involved in surgical research to find other trials or unpublished material or to clarify ambiguous or missing data and posted requests for data on two periodontal electronic discussion groups.

SELECTION CRITERIA

Randomised, controlled trials of at least 12 months duration comparing guided tissue regeneration (with or without graft materials) with open flap debridement for the treatment of periodontal infra-bony defects. Furcation involvements and studies specifically treating early onset diseases were excluded.

DATA COLLECTION AND ANALYSIS

Screening of possible studies was conducted independently by two reviewers (RT & IN) and data abstraction by three reviewers (RT, IN & EGL). The methodological quality of studies was assessed in duplicate (RT & IN) using both individual components and a quality scale (Jadad 1998) and agreement determined by Kappa scores. Methodological quality was used in sensitivity analyses to test the robustness of the conclusions. The Cochrane Oral Health Group statistical guidelines were followed (HW) and the results expressed as weighted mean differences (WMD and 95% CI) for continuous outcomes and relative risk (RR and 95% CI) for dichotomous outcomes calculated using random effects models where significant heterogeneity was detected (P < 0.1). The final analysis was conducted using STATA 6 in order to combine both parallel group studies and intra-individual (split-mouth) studies. The primary outcome measure was gain in clinical attachment. Any heterogeneity was investigated.

MAIN RESULTS

We initially included 23 trial reports. Twelve were subsequently excluded. Of these, seven presented six-months data only, three were not fully randomised controlled trials, one used a non-comparable radiographic technique. Eleven studies were finally included in the review, ten testing GTR alone and two testing GTR+bone substitutes (one study had both test treatment arms). For attachment level change, the weighted mean difference between GTR alone and open flap debridement was 1.11 mm (95% CI: 0.63 to 1.59), chi-square for heterogeneity 31.4 (df = 9), p<0.001) and for GTR+bone substitutes was 1.25 mm (95% CI: 0.89 to 1.61, chi-square for heterogeneity 0.01 (df = 1), p=0.91). GTR showed a significant benefit when comparing the numbers of sites failing to gain 2 mm attachment, with relative risk 0.58 (95% CI: 0.38, 0.88, chi-square for heterogeneity 5.72 (df = 3), p=0.13). The number needed to treat (NNT) for GTR to achieve one extra site gaining 2 mm or more attachment over open flap debridement was 8 (95% CI: 4, 33), based on an incidence of 32% of sites in the control group failing to gain 2 mm or more of attachment. For baseline incidences in the range of the control groups of 10% and 55% the NNTs are 24 and 3. Probing depth reduction demonstrated a small but statistically significant benefit for GTR, weighted mean difference 0.80 mm (95% CI: 0.14,1.46, chi-square for heterogeneity 10.0 (df = 4), p=0.04) or GTR+bone substitutes, weighted mean difference 1.24 mm (95% CI: 0.89, 1.59, chi-square for heterogeneity 0.03 (df = 1), p=0.85). No significant difference was noted for gingival recession between GTR and open flap debridement. Regarding hard tissue probing at surgical re-entry, a statistically significant greater gain was found for GTR compared with open flap debridement. This amounted to a weighted mean difference of 1.39 mm (95% CI: 1.08, 1.71, chi-square for heterogeneity 0.85 (df = 2), p=0.65). For GTR+bone substitutes the difference was greater, with mean difference 3.37 mm (95% CI: 3.14, 3.61). Heterogeneity between studies was highly statistically significant for all principal comparisons and could not be explained satisfactorily by sensitivity analyses. The quality of study reporting was poor with seven out of 11 studies graded as poor using the Jadad score. (ABSTRACT TRUNCATED)

Pain control after routine dento-alveolar day surgery: a patient satisfaction survey

OBJECTIVE

An audit study which examines patient's opinions on the efficiency of two analgesic regimes prescribed to them following dento-alveolar surgery in our Day Unit.

DESIGN

Single centre prospective study.

SETTING

Oral Surgery Day Case Unit

SUBJECTS

One-hundred-and-seventy-four adults undergoing routine dento-alveolar surgery under general anaesthetic were asked to assess their pain control (on a five point scale) 1 hour after surgery, at discharge from hospital and at 24 and 48 hours post-operatively. Post-operatively, patients received ibuprofen 400 mg three times daily for five days or two tablets of paracetamol 500 mg with codeine 30 mg six hourly for 5 days if they were allergic to aspirin or were asthmatics sensitive to aspirin. Patients were not given local anaesthesia intra or post-operatively.

RESULTS

Completed records were obtained for 161 (93%) patients. Ibuprofen was apparently adequate in controlling pain for 147 out of 161 patients but on further questioning 42 of these patients took supplemental analgesics and self-prescribed paracetamol or a paracetamol combination. Thirteen patients who were prescribed paracetamol with codeine had adequate pain control and did not take supplemental analgesics. One patient did not require any analgesics post-operatively

CONCLUSION

Telephone contact with patients 24 and 48 hours post-surgery provides a valuable assessment of pain control following discharge from a day surgery unit. Ibuprofen offered satisfactory control of pain for 65% (95) of patients who underwent routine dento-alveolar surgery. Discharge prescriptions must be given with verbal and written instructions to ensure that patients take the correct dose and self-prescription is within safe doses.

Appropriateness of a Resuscitation Council (UK) advanced life support course for primary care dentists

OBJECTIVES

To investigate whether a standard Resuscitation Council (UK) ALS course is appropriate for primary care dentists or whether a course should be specifically designed for dentists.

DESIGN

Opinions canvassed by pre-course expectation and post-course evaluation questionnaires.

SUBJECTS

23 West Pennine primary care dentists providing a general anaesthetic or conscious sedation service who attended an ALS course.

RESULTS

Knowledge and skills were rated on a 5-point scale from 1 (not important at all) to 5 (extremely important). Basic airway management (mean = 5) and anaphylaxis (mean = 4.9) scored the highest on the 'expectation' questionnaire. Rhythm recognition (P < 0.001), defibrillation (P = 0.007) and arrest algorithms (P = 0.047) were rated as significantly more important after the course than before. Knowledge about rhythm disorder management, cardiac pacing, post-resuscitation care, blood gas interpretation and bereavement were not considered to be so important either before or after the course.

CONCLUSIONS

Despite rating some aspects as unimportant, all dentists stated that this course had been appropriate. They did not want a specially designed ALS course for dentistry. Taking exactly the same recognised course and assessments as other healthcare professionals and gaining the same certification was felt to be important to this group of dentists.

Restorative treatment provided over five years for adults regularly attending general dental practice

OBJECTIVES

To investigate the distribution and type of restorative treatment, including re-treatment, provided for adults who attend annually.

METHODS

In 1991 a selected group of 24 general dental practitioners in the North West of England recruited 4211 of their regularly attending adult patients. Dentists recorded the reason for and type of treatment provided during the following 5 years.

RESULTS

Approximately 40% of the participants received treatment (restorations and/ or extractions) at each annual examination. Of the 2293 patients who attended every examination 1959 (85%) had received a restoration and/ or extraction during the 5 years. A total of 8187 teeth, 15% of those present at baseline, received treatment, 3030 (37%) for caries and 5157 (63%) for other reasons. The proportion of adults who received treatment by age group differed significantly with those aged 25-34 years (80%) being least likely and those 35-44 years of age (89%) most likely. Of the 1744 teeth restored in the first year of the study, 170 (10%) were retreated within 1 year and 402 (23%) during the subsequent 4 years. The 4 year survival of amalgam and tooth coloured fillings was 84% and that of crowns 92%.

CONCLUSIONS

This study documented the extent and type of restorative care provided for regularly attending adults during a 5-year period. The majority of treatment was provided for reasons other than caries. Of the teeth restored over the first year, 23% were retreated in the subsequent 4 years.

Direct access day case oral surgery

OBJECTIVE

To compare the effectiveness of direct access referrals with standard letter referrals, and also assess the impact of the direct access system on the primary care provider, secondary sector and from the patients perspective.

DESIGN

Surgical and anaesthetic guidelines were agreed and 12 general dental practitioners were recruited to participate in the study. Each practitioner was given 100 envelopes which contained randomly allocated 50 direct and 50 standard referrals. For direct referrals, GDPs completed a pre-operative assessment and obtained an operation date by telephone from the day case unit while the patient was in the surgery. The clinical history sheet was faxed to the day unit and the radiographs posted. The only contact the patient had with the hospital was on the day of surgery. Standard referral patients were referred in the traditional way with a referral letter being sent to an out-patient clinic. Evaluation of the effectiveness of the direct referral system versus standard letter method were made via completion of questionnaires by the patients, dental practitioners, hospital clinicians, day case anaesthetist and co-ordinator.

SETTING

The study was carried out over 2 years commencing in 1997 at the Oral Surgery Day Case Unit at Manchester Royal Infirmary.

RESULTS

A greater number of direct access referrals (409; 90%) were treated in comparison with (312; 75%) standard referrals (P < 0.001). Eighty nine per cent of direct access records were adequate pre-operatively. More than 70% of dentists and hospital clinicians preferred the direct access referral method. Sixty-three per cent of standard letter patients were satisfied with their mode of referral compared with 87% of direct access patients.

CONCLUSIONS

Given appropriate guidelines dental practitioners are able to refer directly to oral surgery day case operation lists. This has proved to be the favoured method of referral for dental practitioners, the secondary sector and patients.

Referral patterns and the referral system for oral surgery care. Part 2: The referral system and telemedicine

OBJECTIVE

To investigate GDP opinions of the current referral system and to investigate the need and demand for telemedicine in oral surgery referrals.

DESIGN

Postal questionnaire.

SETTING

400 GDPs in Greater Manchester.

RESULTS

84% participation rate. 48% were not satisfied overall with the service of their current specialist oral surgery referral site. The principal reason was the length of the waiting time for consultation and treatment. Distance for patients to travel to the specialist unit was also of concern, even though most patients (89%) travelled short distances (return journey of twelve miles or less). 23% of respondents wished to improve their ability to communicate with the oral surgeon and 70% wanted involvement in the patient consultation. Both of these requirements were more likely in younger practitioners.

CONCLUSION

There is a need and demand for change in the referral system for oral surgery specialist care. Telemedicine could conceivably be one way to improve access to specialist oral surgery care.

Perceived aesthetic impact of malocclusion and oral self-perceptions in 14-15-year-old Asian and Caucasian children in greater Manchester

The aims of this study were to evaluate (i) the effect of ethnicity, social deprivation, and normative orthodontic treatment need on orthodontic aesthetic self-perception, self-perceived need for orthodontic treatment, and oral aesthetic impact of malocclusion; (ii) the effect of ethnicity, social deprivation, and gender on perceived orthodontic treatment need and use of orthodontic services; (iii) the influence of perceived oral aesthetic impact of malocclusion on perceived need and wish for orthodontic treatment; and (iv) whether orthodontic treatment experience influences perceived oral aesthetic impact of malocclusion. A stratified, random sample of 434 14-15-year-old children from schools in Manchester, UK, was obtained. Information was collected on orthodontic aesthetic self-perception and orthodontic treatment experience using a questionnaire. The former data were combined to form an Oral Aesthetic Subjective Impact Scale (OASIS). Normative orthodontic treatment need was measured with the Index of Orthodontic Treatment Need (IOTN). Children with higher clinical need for orthodontic treatment perceived themselves as worse off than their peers with lower need. More socially deprived children or those with high IOTN aesthetic component (AC) scores had a higher (i.e. more negative) aesthetic impact (OASIS) score. Asians and females had higher IOTN dental health component (DHC) scores, but a better aesthetic appearance than Caucasians and males. More deprived children were less likely to have received orthodontic treatment. Despite this, OASIS scores were similar between treated and untreated children. Untreated children who wished for orthodontic treatment had higher IOTN AC and OASIS scores.

An evaluation of a training programme in primary care research for general dental practitioners

AIMS

To determine whether general dental practitioners would find seminars on research methods in primary care research of interest and whether they would be stimulated to plan their own research.

METHOD

Questionnaire with both open and closed questions distributed to participants at the end of the seminars. 10 seminars in locations throughout the north west of England were planned.

RESULTS

98 dentists attended the seminars of whom 81 returned questionnaires, giving a response rate of 82.6%. More than 60% found the seminars and the specially developed teaching manual very useful. However there was somewhat less enthusiasm for undertaking research projects.

CONCLUSIONS

The findings suggest that some GDPs are interested in primary care research but are not keen to initiate or plan research themselves.