Laminin-5 immunocytochemistry: a new tool for identifying dysplastic cells in oral brush biopsies

BACKGROUND

The brush biopsy technique is not only a seminal technique but also a critically discussed method for detection of oral pre-cancerous stages and manifest carcinomas. The gamma2 chain of laminin-5 and its proteolytic fragments comprise an invasion factor for many carcinomas.

OBJECTIVES

The aim of this study was to determine whether the immunocytochemical presentation of the laminin gamma2 chain identifies pre-invasive or invasive squamous cells in brush biopsies.

METHODS

The value-based identification of atypical epithelia was analysed in 93 consecutive brush biopsies with histopathological diagnoses: standardized haematoxylin and eosin staining; standardized immunocytochemistry: monoclonal antibodies against laminin gamma2 chain: D4B5, 4G1, detection using ChemMate and Autostainer.

RESULTS

Conventional cytology did not result in any false-positive cases, i.e. atypical cells in normal, inflamed or benignly hyperproliferative mucosa (specificity, 100%), whereas immunocytochemistry revealed one false-positive case (specificity, 98%). In brush biopsies of oral squamous cell carcinomas, the following immunocytochemical patterns were possible: (1) staining of the cytoplasm, (2) banded markings between clumped carcinoma cells and (3) positive hazes surrounding atypical cells. Bacterial colonies appeared as false-positive results. Four of 27 carcinomas and one of three recurrences were not cytologically identified (sensitivity of conventional cytology, 79%). Three of the five carcinomas not identified by cytology were immunocytochemically stained with laminin gamma2 chain antibody (sensitivity of laminin gamma2 chain immunocytochemistry, 93%). The positive predictive value was 100% for conventional cytology and 97% for laminin gamma2 chain immunocytochemistry. The negative predictive value attained was 92% for conventional cytology and 97% for laminin gamma2 chain immunocytochemistry.

CONCLUSIONS

The high sensitivity level observed for method-enhanced brush cytology suggests that this technique be used as an initial diagnostic step.

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

BACKGROUND

Previous evaluations showed that literature-search and selection methods reported in dental systematic reviews (SR) have improved since 2000. It is not known, however, whether these differences are consistent between the SR of the different dental specialities.

METHODS

SR in dentistry published in the English language between 1 January 2000 and 14 June 2006 were located and then categorised by American Dental Association (ADA) recognised specialities. Search and selection methods were evaluated following an adaptation of the Cochrane Handbook for Systematic Reviews. Search and selection methods between dental specialities were compared using Pearson's chi-squared analysis and ranked.

RESULTS

There were significant differences between specialities in the following criteria: documentation of search dates (P 0.003); inclusion-exclusion documentation (P 0.017); article selection by two or more reviewers (P 0.001); and inclusion of all languages (P 0.014). Periodontics SR met the most criteria followed by oral and maxillofacial surgery (OMS) and then dental public heath (DPH). Prosthodontics along with the area of oral and maxillofacial radiology (OMR) met the fewest. All dental SR had low compliance with four criteria, only 65.7% searched more than Medline, 50.4% had a search strategy documented with Boolean operators, 51.5% had article selection carried out by two or more reviewers and only 25.7% included all languages.

CONCLUSIONS

Some dental specialities are better at reporting search and selection methods than others but all dental SR need some improvement in their reporting.

Evaluating the quality of randomized controlled trials that examine the efficacy of natural health products: a systematic review of critical appraisal instruments

The purpose of this project was to conduct a systematic review to identify instruments designed to evaluate the quality of randomized controlled trials (RCTs) of natural health products (NHPs). Instruments were examined for inclusion of items assessing methods, identity and content of the NHP, generalizability of results and instructions for use. Online databases, websites, textbooks and reference lists were searched to identify instruments. Relevance assessment and data extraction of articles were completed by two investigators and disagreements were settled by the third investigator. Data were analyzed using descriptive statistics. Of the 4442 citations identified, 29 were potentially relevant with 16 meeting the criteria for inclusion. None of the instruments stated they were validated; content in the four areas of interest varied considerably. The most common items included randomization sequence generation (100%), blinding (100%), allocation concealment (75%) and participant flow (75%). Only nine of the NHP instruments included at least one item to appraise the specific content of the NHP. The CONSORT Statement for Herbal Interventions most closely addressed the four areas of interest; however, this instrument was specific for herbs. There is a need for the development of a validated instrument for assessment of the quality of RCTs that would be useful for herbs as well as other NHPs.

Reproducibility and accuracy of the ICDAS-II for detection of occlusal caries in vitro

AIM

The aim of this study was to assess inter- and intra-examiner reproducibility and accuracy in the detection and assessment of occlusal caries in extracted human teeth using a newly developed visual method for caries diagnosis (International Caries Detection and Assessment System, ICDAS-II). Serial sectioning and microscopy were used as the 'gold standard'.

METHODS

The occlusal surfaces of 100 teeth were examined by 4 dentists using the ICDAS-II graded scores 0-6. Thereafter the teeth were serially sectioned and assessed for depth of the lesion with two histological classification systems.

RESULTS

The weighted kappa values for inter- and intra-examiner reproducibility for the ICDAS-II examination were 0.62-0.83. There was a moderate relationship between the visual and both histological examinations (r(s) = 0.43-0.72). At the D1 diagnostic threshold (enamel and dentine lesions) specificity was 0.74-0.91 and sensitivity was 0.59-0.73. At the D3 diagnostic threshold (dentine lesions) specificity was 0.82-0.94 and sensitivity was 0.48-0.83 for the 4 examiners.

CONCLUSION

The ICDAS-II system has demonstrated reproducibility and diagnostic accuracy for the detection of occlusal caries at varying stages of the disease process which are comparable to previously reported data using similar visual classification systems.

Trigeminal neuralgia: for one nerve a multitude of treatments

Trigeminal neuralgia (TN) is reputed to be one of the most painful conditions in human experience. Thus, many treatments, both medical and surgical, have been developed for this relapsing and remitting, paroxysmal stabbing or electrical, facial pain syndrome. The likely etiology in many cases is vascular compression of the trigeminal nerve root entry zone, leading to focal demyelination and aberrant neural discharges. MRI may disclose neurovascular contact, although not with sufficient sensitivity or specificity to substitute for careful clinical diagnosis. In treating TN, antiepileptic drugs are superior to traditional analgesics. Carbamazepine is the first choice drug. Additional drugs for which there is evidence of efficacy include oxcarbazepine, baclofen, gabapentin, lamotrigine and phenytoin. Many patients eventually experience tachyphylaxis or may not tolerate effective doses. Surgical options include: microvascular decompression; balloon compression; radiofrequency thermocoagulation or glycerol rhizotomies; and subcutaneous alcohol branch blockade. Stereotactic gamma knife radiosurgery is a further option. Motor cortex stimulation and transcranial magnetic stimulation, although having shown initial promise for trigeminal neuropathic pain, seem to be ineffective for classical TN. The choice of drug, whether or when to operate, and which procedure to choose should be individualized to the particular needs and conditions of the patient.

Food choices of edentulous adults with implant-supported overdentures and conventional dentures

DESIGN

A randomised controlled trial (RCT) was carried out involving dental hospital patients.

INTERVENTION

The implant group (IG) were provided with conventional maxillary dentures and implant-retained mandibular overdentures and the denture group (DG) were provided with conventional dentures. Patients consumed seven test foods.

OUTCOME MEASURE

Pre- and post-treatment questionnaires were completed relating to food choices and chewing difficulty.

RESULTS

IG subjects reported increased consumption of carrots, apples and nuts post-treatment (P<0.05) and decreased post-treatment difficulty in chewing apples and nuts. DG subjects reported decreased post-treatment difficulty in chewing carrots, bacon and nuts (P<0.05). Between-group differences for chewing difficulty were detected for nuts, which DG subjects found easier to chew than did IG subjects (P=0.002).

CONCLUSIONS

Food selection and perceived chewing difficulty improved in both groups, with no significant differences between groups. Successful rehabilitation may not result in different food selection, which may require concurrent tailored dietary interventions, but may increase available food choices.

The Hall Technique; a randomized controlled clinical trial of a novel method of managing carious primary molars in general dental practice: acceptability of the technique and outcomes at 23 months

Background

Scotland has high levels of untreated dental caries in primary teeth. The Hall Technique is a simplified method of managing carious primary molars using preformed metal crowns (PMCs) cemented with no local anaesthesia, caries removal or tooth preparation. This study compared the acceptability of the Hall Technique for children, their carers, and dentists, and clinical outcomes for the technique, with conventional restorations.

Methods

General dental practice based, split mouth, randomized controlled trial (132 children, aged 3–10). General dental practitioners (GDPs, n = 17) in Tayside, Scotland (dmft 2.7) placed conventional (Control) restorations in carious primary molars, and Hall Technique PMCs on the contralateral molar (matched clinically and radiographically). Dentists ranked the degree of discomfort they felt the child experienced for each procedure; then children, their carers and dentists stated which technique they preferred. The teeth were followed up clinically and radiographically.

Results

128 conventional restorations were placed on 132 control teeth, and 128 PMCs on 132 intervention teeth. Using a 5 point scale, 118 Hall PMCs (89%) were rated as no apparent discomfort up to mild, not significant; for Control restorations the figure was 103 (78%). Significant, unacceptable discomfort was recorded for two Hall PMCs (1.5%) and six Control restorations (4.5%). 77% of children, 83% of carers and 81% of dentists who expressed a preference, preferred the Hall technique, and this was significant (Chi square, p < 0.0001). There were 124 children (94% of the initial sample) with a minimum follow-up of 23 months. The Hall PMCs outperformed the Control restorations:

a) 'Major' failures (signs and symptoms of irreversible pulpal disease): 19 Control restorations (15%); three Hall PMCs (2%) (P < 0.000);

b) 'Minor' failures (loss of restoration, caries progression): 57 Control restorations (46%); six Hall PMCs (5%) (P < 0.000)

c) Pain: 13 Control restorations (11%); two Hall PMCs (2%) (P = 0.003).

Conclusion

The Hall Technique was preferred to conventional restorations by the majority of children, carers and GDPs. After two years, Hall PMCs showed more favourable outcomes for pulpal health and restoration longevity than conventional restorations. The Hall Technique appears to offer an effective treatment option for carious primary molar teeth.

Trial registration number

Current Controlled Trials ISRCTN47267892 – A randomized controlled trial in primary care of a novel method of using preformed metal crowns to manage decay in primary molar teeth: the Hall technique.

Shirley Glasstone Hughes Memorial Prize for Dental Research: an evaluation of the output 15 years after the Trust's inception

In May 2005, a decision was taken by the Shirley Glasstone Hughes (SGH) Foundation trustees to suspend investments in research for one year, to allow a review of the outcomes of SGH research funding over the past 15 years. Money was instead directed to the BDA Research Unit, to employ a staff member who would conduct the evaluation under the supervision of the BDA Scientific Adviser. The evaluation focused on three aspects of the research produced: 1) relevance to primary dental care, 2) scientific quality and impact on the research community, and 3) grant recipients' feelings about SGH funding and whether the mechanisms of supporting research could be improved. The methods used included questioning BDA members about the research they found of interest and relevance, checking research outputs against standardised quality criteria, examining impact factors and citation rates (relative to the funding received) and questioning grant recipients about their experience with SGH funding. The results implied that the fund had largely been spent on research themes felt to be relevant to practice by BDA members. In addition, the publication rate, publication quality, impact and citation indices demonstrated the SGH research work to be largely of high quality. Recipients of the fund indicated several factors which might improve the experience of receiving funding and possibly also improve the research output. It can be concluded that the SGH funds have largely been well spent but that it is worth considering implementing changes which would make the research findings of greater relevance to clinical practice.

Single versus multiple visits for endodontic treatment of permanent teeth

BACKGROUND

Root canal treatment (RoCT), or endodontic treatment, is a common procedure in dentistry. The main indications for RoCT are irreversible pulpitis and necrosis of the dental pulp caused by carious processes, tooth cracks or chips, or dental trauma. Successful RoCT is characterised by an absence of symptoms and clinical signs in teeth without radiographic evidence of periodontal involvement. The success of RoCT depends on a series of variables related to the preoperative condition of the tooth, as well as the endodontic procedures.

OBJECTIVES

To compare the effectiveness of single- and multiple-visit RoCT, measured as tooth extraction due to endodontic problems and radiological success.To assess the difference in short- and long-term complications between single- and multiple-visit RoCT.

SEARCH STRATEGY

The following databases were searched for relevant trials: Cochrane Oral Health Group's Trials Register, CENTRAL, MEDLINE, and EMBASE. Handsearching was performed for the major oral medicine journals. References of included studies and reviews were checked. Endodontics experts were contacted through e-mail. No language limitations were imposed. Date of last search was 6th March 2007.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials of patients needing RoCT were included. Surgical endodontic treatment was excluded. The outcomes considered were the number of teeth extracted for endodontic problems; radiological success after at least 1 year, that is, absence of any periapical radiolucency; postoperative pain; painkiller use; swelling; or sinus track formation.

DATA COLLECTION AND ANALYSIS

Data were collected using a specific extraction form. The validity of included studies was assessed on the basis of allocation concealment, blindness of the study, and loss of participants. Data were analysed by calculating risk ratios. When valid and relevant data were collected, a meta-analysis of the data was undertaken.

MAIN RESULTS

Twelve randomised controlled trials were included in the review. Four studies had a low risk of bias, four a moderate risk, and another four had a high risk of bias. The frequency of radiological success and immediate postoperative pain were not significantly different between single- and multiple-visit RoCT. Patients undergoing single-visit RoCT reported a higher frequency of painkiller use and swelling, but the results for swelling were not significantly different between the two groups. We found no study that included tooth loss and sinus track formation among its primary outcomes.

AUTHORS' CONCLUSIONS

No difference exists in the effectiveness of RoCT, in terms of radiological success, between single- and multiple-visit RoCT. Most short- and long-term complications are also similar in terms of frequency, although patients undergoing a single visit may experience a slightly higher frequency of swelling and are significatively more likely to take painkillers.

Perioperative Management of Anticoagulant Therapy during Cutaneous Surgery: 2005 Survey of Mohs Surgeons

BACKGROUND

The perioperative management of anticoagulation and antiplatelet therapy is a controversial topic in the field of dermatologic surgery. Dermasurgeons must weigh the risk of bleeding against the risk of thrombotic complications when deciding how to manage perioperative anticoagulation.

OBJECTIVE

Our aim is to present a summary of current practice in anticoagulation management perioperatively during cutaneous surgery. We compare our results to those found in a similar survey in 2002.

METHODS AND MATERIALS

A questionnaire surveying current practice in perioperative management of anticoagulant therapy was mailed to 720 dermasurgeons.

RESULTS

Thirty-eight percent of dermasurgeons responded to the questionnaire. Of the responding physicians, 87% discontinue prophylactic aspirin therapy, 37% discontinue medically necessary aspirin, 44% discontinue warfarin, 77% discontinue nonsteroidal anti-inflammatory drugs (NSAIDs), and 77% discontinue vitamin E therapy perioperatively at least some of the time. Although clopidogrel was not surveyed, 78 physicians included comments about the management of this agent.

CONCLUSION

Dermasurgeons were more likely to continue medically necessary aspirin and warfarin in 2005 compared to 2002, with the most dramatic shift evident in the management of warfarin. They were more likely to discontinue prophylactic aspirin, NSAIDs, and vitamin E. Surgeons were concerned about bleeding with the antiplatelet agent clopidogrel. More evidence-based medicine is necessary to set guidelines for the management of anticoagulation and antiplatelet therapy perioperatively.

Routine oral examination: clinical performance and management by general dental practitioners in primary care

The aim of this clinical study was to explore the contents of routine oral examinations (ROE), carried out by Dutch general dental practitioners (GDPs), in relation to the oral health status of regularly attending patients. An observational study was performed, based on clinical case recording. Using The Data Station Project of the Dutch Dental Association as the study base, 215 GDPs were recruited, of whom 131 participated in the study. A clinical case-recording form was developed to document clinical behavior. The contents assessed concerned patient characteristics, contents of the ROE visit, diagnoses made, and clinical behavior in response to ROE findings. This study showed substantial variation in clinical behavior related to specific ROE domains, including patient history and record keeping, whereas GDPs acted consistently on other domains, such as clinical examination and recall length assessment. Furthermore, the ROE performance was more strongly associated with GDP characteristics than with patient characteristics. The mean ROE time was 10 min, and recall intervals were most frequently assigned at 6 months, irrespective of the oral condition. This study highlights a need for continuing education to promote risk-based oral screening. Further research is needed to identify factors responsible for the variation in GDP performance, just as research on clinical practice guideline implementation methods is warranted.

Urinary fluoride reference values determined by a fluoride ion selective electrode

As fluoride has a very short half-life in the body and the major route for fluoride excretion is via the kidney, human exposure is best measured in urine, where the concentration is expected to be highest. The urinary fluoride concentrations of 167 healthy Japanese adults were determined by means of a fluoride ion selective electrode. When the results were corrected for a specific gravity rho = 1.024 g cm-3, the histogram of urinary fluoride concentrations highly skewed toward low values with sharp peakedness (skewness = 1.56, kurtosis = 3.08). The normality of the log-transformed histogram (skewness = 0.12, kurtosis = 0.07) and the straight line on log-probability paper clearly showed a key feature of lognormal distribution of urinary fluoride. A geometric mean (GM) of 613.8 microg/l and 95% confidential interval (CI) of 241.0-1633.1 microg/l were established as reference values for urinary fluoride. The results presented in this study will be useful as guidelines for the biological monitoring of fluoride in normal subjects and individuals at risk of occupational or environmental fluoride exposure.

No definitive conclusion as to the most effective method of pulp treatment of asymptomatic carious teeth

DATA SOURCES

The Cochrane Oral Health Group's Trials Register, Cochrane Central Register of Controlled Trials, Medline, Embase, National Research Register and the Science Citation Index SCISEARCH were searched. Key journals were searched by hand, together with reference lists of review articles and endodontic textbooks. There was no language restriction.

STUDY SELECTION

Randomised controlled trials (RCT) or quasi-RCT were included that compared techniques to maintain pulp vitality of asymptomatic permanent teeth with extensive caries. Outcome measures included clinical success and adverse events.

DATA EXTRACTION AND SYNTHESIS

Data were independently extracted by three review authors and, where necessary, further information was sought from the author. The quality of included studies was assessed using standard criteria.

RESULTS

The search identified 34 studies of which four met the inclusion criteria. Interventions examined included: Ledermix (Wyeth Lederle, Denmark), glycerrhetinic acid/ antibiotic mix, zinc oxide eugenol, calcium hydroxide, Cavitec (Kerr Corporation, Orange, CA 92867), Life (DENTSPLY Caulk, Milford, DE 19963-0359), Dycal (DENTSPLY Caulk, Milford, DE 19963-0359)potassium nitrate, dimethyl isosorbide, and polycarboxylate cement. Only one study produced a statistically significant finding: potassium nitrate/ dimethyl isosorbide/ polycarboxylate cement resulted in fewer clinical symptoms than potassium nitrate/ polycarboxylate cement or polycarboxylate cement alone when used as a capping material for carious pulps.

CONCLUSIONS

The findings of this review suggest that there should not be any significant change from accepted conventional practice procedures when the pulp of the carious tooth is considered. Further well-designed RCT are needed to investigate the potential of contemporary materials which may be suitable when used in the management of carious teeth.

External bleaching effect on the color and luminosity of inactive white-spot lesions after fixed orthodontic appliances

OBJECTIVE

To evaluate the effect of external bleaching on the color and luminosity of inactive white-spot lesions (WSLs) present after fixed orthodontic appliance treatment as means for achieving color matching of the WSLs with adjacent tooth surfaces.

MATERIALS AND METHODS

Ten patients with inactive WSLs after therapy with fixed orthodontic appliances were selected. At baseline, the lightness of maxillary incisors and canines was assessed with a colorimeter. Color determinations were performed in the area of the initial lesions (F1) and at adjacent, sound enamel areas (F2). Then, anterior teeth were bleached once with a bleaching gel for 60 minutes. After a break of 14 days, in-office bleaching was followed by a 2-week home bleaching period with daily home bleaching for 1 hour. After this, color determinations were repeated. Additionally, patients were asked to fill out a questionnaire to provide information about their degree of contentment with the treatment.

RESULTS

The lightness values of both the F1 and F2 regions were significantly higher after bleaching as compared with baseline. F2 L-values increased significantly more as compared with F1, indicating a better color matching of these two areas in comparison with baseline. All patients were satisfied with the outcome of the bleaching therapy.

CONCLUSION

External bleaching is able to satisfactorily camouflage WSLs visible after therapy with fixed orthodontic appliances.

Caries management: technical solutions to biological problems or evidence-based care?

Caries-related clinical decision-making remains a centrepiece of clinical dentistry. However, the oral disease patterns are rapidly changing towards the better among major sections of the populations, most notably in the high-income countries. The caries decline is well documented among children and younger adults, and is gradually seen to trickle into middle and old age as well. Although it is tempting for the dental profession to take the credit for this development, the evidence points in a different direction. The major contribution of dentistry seems primarily related to changes in the treatment philosophies towards a less interventionist approach. This review aims to spur a further change in the diagnostic and treatment criteria used in the management of dental caries for the benefit of the oral health status of our patients. We must come to terms with the fact that our traditional core skills, our manual dexterity and technical competence, have less to offer to oral health than we have been accustomed to think. The dental schools and the professional dental organizations must carry the responsibility for promoting the necessary changes in the caries related clinical decision-making strategies to allow practicing dentists to provide appropriate oral health care to our populations.

Oral health-related quality of life: a critical appraisalof assessment tools used in elderly people

OBJECTIVE

The purpose of this study was to undertake a critical appraisal of oral health-related quality of life (OHRQoL) measurements used for research in the elderly.

BACKGROUND

A variety of OHRQoL measurements have been developed in the past 20 years as a result of increased concern about the impact of oral conditions on a person's quality of life. There is need for an assessment aimed at prioritising the recommended measurements to be used for different purposes in the elderly.

MATERIALS AND METHODS

Original English language papers using measurements to assess OHRQoL in the elderly were identified from Web of Science, EMBASE, PubMed, Medline and Lilacs databases. The search included all papers published from 1985 to February 2007. The criteria of assessment were: (i) measurement criteria (number of items and domains, and classification of the results found for each measurement); (ii) quantitative-qualitative criteria (frequency, acceptability, reproducibility, reliability, sensitivity and capability of being reproduced in other language versions).

RESULTS

In a total of 152 papers selected, 20 measurements were identified. However, only seven fulfilled all the measurement and quantitative-qualitative criteria.

CONCLUSION

Geriatric Oral Health Assessment Index, Subjective Oral Health Status Indicators, Oral Health Impact Profile-49, Dental Impact on Daily Living, Oral Health Impact Profile-14, Oral Impact on Daily Performances and German Version of the Oral Heath Impact Profile were considered as instruments of choice to assess OHRQoL in the elderly. The other 13 instruments identified require further research aimed at a validation process and the use of a language other than English.

Assessment of Autofluorescence to Detect the Remineralization Capabilities of Sodium Fluoride, Monofluorophosphate and Non-Fluoride Dentifrices

The purpose of the study was to determine if longitudinal measurements of enamel autofluorescence (quantitative light-induced fluorescence, QLF) could detect differences in remineralization of early enamel caries on buccal surfaces of anterior teeth following supervised daily brushing with either sodium fluoride (NaF; 1,450 ppm F), sodium monofluorophosphate (MFP; 1,450 ppm F) dentifrices or a herbal, non-fluoride placebo dentifrice. The study was a pragmatic cluster-randomized controlled trial with schools as the unit of randomization. Twenty-one schools in Chengdu, China, comprised the clusters; 296 children with at least 1 visible white-spot lesion were examined using QLF at baseline and after 3 and 6 months. Each of the 21 clusters was randomly assigned 1 of the 3 dentifrices, and the children brushed under supervision once per day for 2 min. The primary outcome measure was deltaQ (product of fluorescence loss and area) at a 5% threshold after 6 months of product use. A multi-level model was fitted to the data at the site level, taking into account the hierarchical structure with baseline deltaQ, age and sex as covariates. After 3 months there was a significant difference between the MFP group and placebo (p = 0.02) and after 6 months between the NaF group (p = 0.002), MFP group (p < 0.001) and the placebo. QLF methodology could detect, within 3- and 6-month periods of supervised brushing, a difference in remineralization between fluoride-containing and non-fluoride-containing dentifrices. Typically lesions in all 3 treatment groups demonstrated improvement. Groups receiving fluoride experienced a more rapid and more substantial remineralization than those in the placebo group.

Mutans streptococci colonization and longitudinal caries detection with laser fluorescence in fissures of newly erupted 1st permanent molars

OBJECTIVE

To longitudinally apply a laser fluorescence (LF) device (DIAGNOdent) in newly erupted 1st permanent molars over a 3-year period and to relate the findings to mutans streptococci (MS) colonization, fissure morphology, and caries development.

MATERIAL AND METHODS

The material consisted of 101 consecutive 5 to 6-year-old children attending a Public Dental Clinic and who volunteered after ethical approval and informed consent had been given. Only fully erupted molars with clinically sound fissures were included. At baseline, the fissures were subjectively categorized as "shallow" or "deep", and, prior to the LF readings, a plaque sample was collected and cultivated for MS using a chair-side kit. The registrations were repeated annually and the microbial samplings after 2 years. The total drop-out rate was 12%.

RESULTS

The mean LF values increased significantly (p<0.05) with increasing age from 8.2 to 12.4 in the teeth that remained sound. Thirty-five teeth were decayed or filled during the follow-up and their mean LF values increased from 13.4 to 40.7. The LF readings were significantly higher in molars with "deep" fissures (p<0.05) at all visits. MS colonization at baseline was associated with an increased risk for caries (OR = 11.6, p<0.05) and significantly elevated LF readings. Baseline LF readings > or =12 were not diagnostic for dentin caries or fillings over the study period (sensitivity 0.57; specificity 0.86).

CONCLUSION

LF readings could be used to some extent to monitor fissure morphology and caries development in fissures of newly permanent molars over time, but elevated initial values were not predictive for caries development.

The association between Helicobacter pylori infection and early gastric cancer: a meta-analysis

OBJECTIVE

Helicobacter pylori (H. pylori) is recognized as a definite carcinogen for gastric cancer. The prevalence of H. pylori infection in patients with gastric cancer varies widely among studies and no meta-analysis on the prevalence of H. pylori infection in early gastric cancer (EGC) has been performed. We aimed to review systematically the relationship between H. pylori infection and EGC, and different types of EGC.

METHODS

Observational studies reporting raw data on the prevalence of H. pylori infection in EGC and controls, or comparing different types of EGC, conducted in adult populations, and published in the English language were identified through MEDLINE and EMBASE up to June 2006.

RESULTS

Of 87 relevant studies, 19 case-control studies met inclusion criteria. Of these, 15 studies compared EGC (N = 2,722) and non-neoplasm controls (N = 13,976) or advanced gastric cancer (AGC) (N = 1,130), 9 studies compared the intestinal-type (I-EGC) and diffuse-type (D-EGC) of EGC, and 2 studies compared the differentiated-type (DF-EGC) and undifferentiated-type (UDF-EGC) of EGC and were included in the meta-analysis. The prevalence of H. pylori infection was significantly higher in patients with EGC (87.3%) than in non-neoplasm controls (61.4%) (OR 3.38, 95% CI 2.15-5.33, P < 0.00001). However, significant heterogeneity was seen (P < 0.00001). Four large sample (N > or = 100) studies (N = 2,060) may result in the heterogeneity, but the conclusion remained unchanged when sensitivity analysis was made with the other 11 homogeneous small sample studies alone, in which the prevalence of H. pylori infection was significantly higher in EGC (N = 662) than that in controls (N = 5,898) (87.8%vs 68.6%, P < 0.00001), and the odds ratio (OR 3.28, 95% CI 2.34-4.61) was similar to the large sample studies alone (OR 3.40, 95% CI 1.14-10.12). The prevalence of H. pylori infection in EGC was significantly higher than in AGC (6 studies) (OR 2.13, 95% CI 1.75-2.59) and 16-fold higher in patients with DF-EGC than in those with UDF-EGC (OR 16.53, 95% CI 2.64-103.43). No significant difference in the prevalence of H. pylori infection was seen between the patients with I-EGC and D-EGC types (OR 0.75, 95% CI 0.26-2.18).

CONCLUSIONS

This study indicates that H. pylori infection is strongly associated with early gastric cancer when compared with non-neoplasm controls or advanced gastric cancer. To determine more accurately the effect size of H. pylori in EGC, age-matched normal controls or adjusting for age in the analysis should be considered in H. pylori-related gastric cancer case-control studies.

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

DATA SOURCES

Medline and the Cochrane library databases were searched and additional studies located by scrutinising publications obtained.

STUDY SELECTION

Studies included in analysis were randomised controlled trails (RCT) about prevention of alveolar osteitis (AO) that were written in English, French, German or any of the Nordic languages (Danish, Finnish, Icelandic, Norwegian, Swedish). Duplicate publications, those with flawed data and RCT that generally addressed postoperative complications were excluded.

DATA EXTRACTION AND SYNTHESIS

The RCT were quality assessed using the Jadad scale and then categorised and tabulated, according to the main test interventions, to the following domains: antibiotics trials; chlorhexidine trials; trials of PEPH (an antifibrinolytic-active propylic ester of p-hydrobenzoic acid); and other trials including factorial trials (combined interventions) and factorial test groups of RCT belonging to any of the aforementioned domains.

RESULTS

A total of 90 publications were identified, from which 32 RCT were included, from 12 different countries, covering the time period 1971-2005. An adequate method of random allocation was reported in 47% of the RCT. Eight different RCT assessed different antibiotic regimens. Tetracycline trials revealed the greatest preventive effects on AO, with absolute risk reductions (ARR) ranging from 12-31% and numbers needed to treat (NNT) ranging from three to eight treated individuals. The effect of chlorhexidine rinses for prevention of AO was studied in five RCT with ARR ranging from 3-25% (NNT, four to 36 treatments). Overall, evidence about chlorhexidine rinses on the prevention of AO was inconclusive, but the available data indicate that 0.12% chlorhexidine rinsing pre-operatively and 7 days postoperatively reduces the frequency of AO following surgical removal of lower third molars. Similarly, evidence for the effectiveness of the antifibrinolytic agent PEPH (considered in three trials) was inconclusive, as was that for the other 18 trials agents.

CONCLUSIONS

Local treatment with tetracycline, and also 0.12% chlorhexidine rinsing pre-operatively and 7 days postoperatively, seem to have significant and clinically relevant preventive effect on AO following surgical removal of lower third molars.

High relative frequency of oral squamous cell carcinoma in Yemen: qat and tobacco chewing as its aetiological background

To study the association of qat chewing with the occurrence of oral cancer, the frequency of oral cancer among whole body cancers and the patients' histories of tobacco consumption and qat chewing were examined in Yemen where qat chewing has been most popular. All primary malignant tumors listed in the surgical pathology files at Al-Thawra Hospital, University of Sana'a, in the year 2004 were analyzed, and the patients' histories of tobacco consumption and qat chewing were examined. A total of 649 cases of primary malignant tumors (348, 53.6% males and 301, 46.4% females) were extracted. Oral cancer was the most frequent body cancer in both males (17.2%) and females (19.6%). Squamous cell carcinoma (SCC) was the most frequent oral cancer (84%), and the tongue (42%), gingiva (23%) and buccal mucosa (20%) were the most common sites. Among the 119 patients with oral cancer, information on chewing habits and smoking was obtained in 92 patients (77.3%). There were 70 tobacco chewers (76.1%), 55 qat chewers (59.8%), and 22 smokers (23.9%). Simultaneous chewing of tobacco and qat was found in 48 cases (52.2%). The present survey has disclosed for the first time that oral SCC is the most frequent cancer in this study area in Yemen, and that the high relative frequency of oral SCC may be related to the habits of chewing tobacco and qat.

Caries experience among 45–54 year olds in Adelaide, South Australia

BACKGROUND

Middle-aged adults are an important focus of dental policy with increasing retention of teeth and use of dental services. The aims of the study were to describe the caries experience of 45-54 year olds by dental visit pattern, dental behaviour, socio-demographics and socio-economic status.

METHODS

A random sample of 45-54 year olds from Adelaide, South Australia was surveyed by self-complete questionnaire during 2004-2005 with up to four follow-up mailings to non-respondents (n=879, response rate = 43.8 per cent). Oral examinations were performed by calibrated dentists on 709 persons (completion rate = 80.7 per cent).

RESULTS

The mean number (95% CI) of decayed teeth was 0.39 (0.31-0.47), with 5.25 (4.92-5.58) missing teeth, 11.0 (10.62-11.32) filled teeth, and DMFT was 16.61 (16.21-17.01). Multivariate regressions of caries experience by dental visit pattern, dental behaviour, socio-demographics and socio-economic status found: time since last visit of less than 12 months was related (P < 0.05) to fewer decayed teeth (beta = -0.40), more filled teeth (beta = 1.55) and a higher DMFT (beta = 1.24); a last visit for relief of pain was related to more decayed teeth (beta = 0.56); tooth brushing 8+ times per week was related to fewer decayed (beta = -0.36), and missing teeth (beta = -1.13), and lower DMFT (beta = -1.58); not cleaning between teeth was related to more missing teeth (beta = 0.94); males had fewer missing teeth (beta = -0.76); having a diploma/degree was related to fewer missing teeth (beta = -1.07) and lower DMFT (p = -1.27); card holder status was related to more missing teeth (beta= 1.26); and household income of $80,000+ was related to fewer missing teeth (beta= -0.96) and a lower DMFT (beta= -1.35).

CONCLUSIONS

Dental visit pattern, dental behaviour, socio-demographics and socio-economic status were all related to caries experience. Overall DMFT was lower for those who brushed more frequently, had higher levels of education and higher household income.

Dental findings and dental care management in trisomy 18: case report of a 13-year-old "long-term survivor"

Trisomy 18 is a disorder characterized by psychomotor disabilities, dysmorphic features and organ malformations, including mental disabilities, growth deficiency, poor motor ability, micrognathia, microcephaly, low-set and malformed ears, distinctively clenched fists with overlapping fingers, and congenital heart defects. The prognosis is poor: 90% of infants with trisomy 18 do not survive beyond the first year of life and 99% die before the age of 10. This paper reports on a 13-year-old child diagnosed with trisomy 18. The major clinical features are cleft lip/palate, high-arched narrow palate, micrognathia, anterior open bite, posterior crossbite and taurodontism. Dental care management of these patients with special needs is discussed and the dental treatment for this child with trisomy 18 is described.

Evidence Based Complementary and Alternative Medicine: Promises and Problems

OBJECTIVE

The present paper examines the experience of establishing a center for evidence-based complementary and alternative medicine (EBCAM) practice. It examines both the difficulties and the challenges of doing research to establish EBCAM. The paper also examines the political context of the demand for evidence- based practice (EBP) for CAM.

IMPLEMENTATION

A center for EBCAM was funded for 3 years within the Southern California Evidence-Based Practice Center by the National Center for CAM and administered by the Agency for Health Research Quality. This experience provides the basis for this paper.

RESULTS

While the experience of creating an EBM Center for CAM has shown that much work can be accomplished by applying standard methods of EBP medicine, it also highlights the weaknesses of such an agenda. Many standard research methods are simply not applicable to CAM, and even where they are, effectiveness is a much more important means of assessing CAM than simply efficacy. Researchers however, must be conscious of the political motivations behind much of the demand for EBCAM. Where such demands are coming from allopathic medicine, they clearly form a continuing part of medical opposition to CAM and may be intended to perpetuate the dominance of the biomedical paradigm in healthcare. The challenge for CAM is to recognize the limitations of EBP but not to throw the 'baby out with the bathwater'. There is much in EBP that clearly should be emulated by the CAM community but only where it is appropriate.

A cluster randomised controlled trial in primary dental care based intervention to improve professional performance on routine oral examinations and the management of asymptomatic impacted third molars: study protocol

BACKGROUND

Routine oral examination (ROE) refers to periodic monitoring of the general and oral health status of patients. In most developed Western countries a decreasing prevalence of oral diseases underpins the need for a more individualised approach in assigning individualised recall intervals for regular attendees instead of systematic fixed intervals. From a quality-of-care perspective, the effectiveness of the widespread prophylactic removal of mandibular impacted asymptomatic third molars (MIM) in adolescents and adults is also questionable. Data on the effectiveness of appropriate interventions to tackle such problems, and for promoting continuing professional development in oral health care are rare.

METHODS/DESIGN

This study is a cluster randomised controlled trial with groups of GDPs as the unit of randomisation. The aim is to determine the effectiveness and efficiency of small group quality improvement on professional decision-making of general dental practitioners (GDPs) in daily practice. Six peer groups ('IQual-groups') shall be randomised either to the intervention arm I or arm II. Groups of GDPs allocated to either of these arms act as each other's control group. An IQual peer group consists of eight to ten GDPs who meet in monthly structured sessions scheduled for discussion on practice-related topics. GDPs in both trial arms receive recently developed evidence-based clinical practice guidelines (CPG) on ROE or MIM. The implementation strategy consists of one interactive IQual group meeting of two to three hours. In addition, both groups of GDPs receive feedback on personal and group characteristics, and are invited to make use of web-based patient risk vignettes for further individual training on risk assessment policy. Reminders (flow charts) will be sent by mail several weeks after the meeting. The main outcome measure for the ROE intervention arm is the use and appropriateness of individualised risk assessment in assigning recall intervals, and for the MIM-intervention group the use and appropriateness of individualised mandibular impacted third molar risk management. Both groups act as each other's control. Pre-intervention data will be collected in study months one through three. Post-intervention data collection will be performed after nine months.

Single-dose and multi-dose clindamycin therapy fails to demonstrate efficacy in preventing infectious and inflammatory complications in third molar surgery

The goal of this study was to evaluate the efficacy of single- and multi-dose (5-day) clindamycin therapy for the prevention of inflammatory complications in patients undergoing lower third molar surgical extraction with bone removal. Patients who qualified for the prospective, randomized, double-masked, placebo-controlled trial were randomly divided into three groups: (1) single dose of oral clindamycin administered preoperatively (single-dose group); (2) clindamycin administered preoperatively with continued therapy for 5 days (5-day group); and (3) a placebo group. The following parameters were evaluated on the first, second and seventh days postsurgery: trismus, facial swelling, body temperature, lymphadenopathy, alveolar osteitis and subjective pain sensations. There were 86 patients (31 in the single-dose group, 28 in the 5-day group and 27 in the placebo group) enrolled in the study. There were no statistically significant differences in postoperative inflammatory complications in patients during the first and second days postsurgery. A statistically significant variation in body temperature was reported on the seventh day. Analysis of the postoperative analgesic intake did not show statistically significant differences between examined groups. Clindamycin applied in a single preoperative dose of 600 mg with or without subsequent 5-day therapy does not demonstrate efficacy in prophylaxis for postoperative inflammatory complications after third molar surgery.

The relationship of medical and dental factors to perceived general and dental health

OBJECTIVE

To determine the relative importance of dental and medical features in relation to perceived oral and general health in a sample of 31-year-old individuals.

SUBJECTS AND METHODS

The present study used information collected from the longitudinal Cardiff Survey, which commenced in 1981. The initial sample consisted of 1018 11-year-old Caucasian schoolchildren. Three hundred and thirty-seven individuals attended the latest examination in 2001 (aged 31 years). For every individual who attended in 2001, the following information was collected: perceived general and oral health recorded on a five-point Likert scale; self-reported medical history; SF-36v(2) questionnaire; assessment of dental features; and the Index of Complexity, Outcome and Need (ICON).

RESULTS

Ninety-four and 82% of individuals reported good-excellent general and oral health, respectively. Females reported a higher level of physical health than males as measured using the SF-36v( 2). Four medical conditions were associated with perceived poor general health: mental [odds ratios (OR); 95% confidence limits (95% CI): 4.5; 1.1-18.4], gastrointestinal (OR 3.4; 95% CI 1.2-9.5) and genitourinary disorders (OR 7; 95% CI 1.6-30.2), and conditions that did not readily fit into a defined category or system (OR 12.8; 95% CI 3.9-42.3). The highest prevalence of dental factors was gingivitis followed by gingival recession and plaque. Photographically assessed dental factors associated with self-reported poor/fair oral health were fillings (OR 0.45; 95% CI 0.2-0.9), root caries/abrasion (OR 0.37; 95% CI 0.1-0.9) and gingivitis (OR 0.31; 95% CI 0.1-0.9). There was a statistically significant association between oral and general health. Of those individuals reporting fair-poor oral health (18%), the proportion also reporting fair-poor general health was 63.6%. Unexpectedly, per-unit increase in ICON score was also significantly associated with fair-poor general health (OR 0.97) with clinically relevant increases of 7 ICON units producing an OR of 0.82.

CONCLUSION

The relative importance of the various dental and medical conditions has been identified. Further studies are required to explore the importance of ICON in perceived medical health and importance of the various conditions on oral and general health over different age groups.