Pharmaceutical prescribing for children. Part 3. Antibiotic prescribing for children with odontogenic infections

This paper is the third in a series on the prescribing of medicines for children by dentists working in primary care. It deals with antibiotics, which may be prescribed for infections arising from teeth, and reviews current best practice.

Science versus empiricism

Few debates within dentistry have aroused such strong feelings as the issue of orthodontic growth guidance. Most orthodontists consider that appliances have little influence beyond the teeth and alveolus. If there is not room, it is argued, extractions are inevitable. Despite this a sizable minority, mostly of general dentists, believe that it is possible to influence skeletal form significantly. Why is there such lack of consensus?

Palatal development of preterm and low birthweight infants compared to term infants - What do we know? Part 1: The palate of the term newborn

Background

The evidence on prematurity as 'a priori' a risk for palatal disturbances that increase the need for orthodontic or orthognathic treatment is still weak. Further well-designed clinical studies are needed. The objective of this review is to provide a fundamental analysis of methodologies, confounding factors, and outcomes of studies on palatal development. One focus of this review is the analysis of studies on the palate of the term newborn, since knowing what is 'normal' is a precondition of being able to assess abnormalities.

Methods

A search profile based on Cochrane search strategies applied to 10 medical databases was used to identify existing studies. Articles, mainly those published before 1960, were identified from hand searches in textbooks, encyclopedias, reference lists and bibliographies. Sources in English, German, and French of more than a century were included. Data for term infants were recalculated if particular information about weight, length, or maturity was given. The extracted values, especially those from non-English paper sources, were provided unfiltered for comparison.

Results

The search strategy yielded 182 articles, of which 155 articles remained for final analysis. Morphology of the term newborn's palate was of great interest in the first half of the last century. Two general methodologies were used to assess palatal morphology: visual and metrical descriptions. Most of the studies on term infants suffer from lack of reliability tests. The groove system was recognized as the distinctive feature of the infant palate. The shape of the palate of the term infant may vary considerably, both visually and metrically. Gender, race, mode of delivery, and nasal deformities were identified as causes contributing to altered palatal morphology. Until today, anatomical features of the newborn's palate are subject to a non-uniform nomenclature.

Conclusion

Today's knowledge of a newborn's 'normal' palatal morphology is based on non-standardized and limited methodologies for measuring a three-dimensional shape. This shortcoming increases bias and is the reason for contradictory research results, especially if pathologic conditions like syndromes or prematurity are involved. Adequate measurement techniques are needed and the 'normal palatal morphology' should be defined prior to new clinical studies on palatal development.

Cost-benefit, cost-effectiveness and cost-utility analyses of periodontitis prevention

OBJECTIVE

The aim of this paper was to determine whether there is evidence that periodontitis prevention is economically justified.

MATERIAL AND METHODS

The characteristics of economic assessments such as cost-benefit, cost-effectiveness and cost-utility analyses were first derived from the literature on health economy. A literature search was conducted using PubMed up to December 2004. Inclusion criteria required that economic analyses be based on scientific principles including a hypothesis, valid comparative groups as well as a cost/benefit, cost/effectiveness and cost/utility assessment.

RESULTS

Only 14 papers were located, which included, in the broadest sense, economic parameters. From these papers, three were systematic reviews, three were randomized controlled studies, four were controlled studies, one was a longitudinal cohort study and three papers were based on statistical modelling. Only one paper reported actual costs for periodontal and dental treatment. Extensive programmes aimed at prevention of periodontal disease in a general population group showed no economic benefit. Adjunctive genetic/and or microbiological testing likewise showed no economic benefit. Economic assessments and real costs are not generally available in the literature. Statistical modelling suggested that non-surgical periodontal procedures are more economical compared with surgical interventions. The use of local delivery devices as an adjunct to Sc/RP showed no economic advantage.

CONCLUSION

It is suggested that economic parameters as well as patient-centred outcomes be included in clinical trials. These data are essential for the appropriate allocation of resources for preventive measures on an individual patient and population base.

Dental hygiene participation in managing incipient and hidden caries

With the advent of new caries detection devices that allow early detection, dental hygienists can intervene in the demineralization process and work with the patient toward remineralization through patient self-care procedures and the professional application of topical fluorides. The focus of this article is on caries detection devices, caries risk assessment, agents used to prevent dental caries, and the development of self-care plans for patients that include prevention, intervention, and therapeutic components.

Predictors of failed attendances in a multi-specialty outpatient centre using electronic databases

Background

Failure to keep outpatient medical appointments results in inefficiencies and costs. The objective of this study is to show the factors in an existing electronic database that affect failed appointments and to develop a predictive probability model to increase the effectiveness of interventions.

Methods

A retrospective study was conducted on outpatient clinic attendances at Tan Tock Seng Hospital, Singapore from 2000 to 2004. 22864 patients were randomly sampled for analysis. The outcome measure was failed outpatient appointments according to each patient's latest appointment.

Results

Failures comprised of 21% of all appointments and 39% when using the patients' latest appointment. Using odds ratios from the mutliple logistic regression analysis, age group (0.75 to 0.84 for groups above 40 years compared to below 20 years), race (1.48 for Malays, 1.61 for Indians compared to Chinese), days from scheduling to appointment (2.38 for more than 21 days compared to less than 7 days), previous failed appointments (1.79 for more than 60% failures and 4.38 for no previous appointments, compared with less than 20% failures), provision of cell phone number (0.10 for providing numbers compared to otherwise) and distance from hospital (1.14 for more than 14 km compared to less than 6 km) were significantly associated with failed appointments. The predicted probability model's diagnostic accuracy to predict failures is more than 80%.

Conclusion

A few key variables have shown to adequately account for and predict failed appointments using existing electronic databases. These can be used to develop integrative technological solutions in the outpatient clinic.

Routine oral examination: differences in characteristics of Dutch general dental practitioners related to type of recall interval

OBJECTIVES

The aim of this study was to explore differences in behaviour (characteristics and opinions) among general dental practitioners (GDPs), using either a fixed (Fx) or an individualized recall interval (Iv) between successive routine oral examinations (ROEs).

METHODS

In the year 2000, data were collected by means of a written questionnaire sent to a random stratified sample of 610 dentists of whom 521 responded, of which 508 (83%) were used for analysis.

RESULTS

Two groups of GDPs were distinguished based on their answer to the question: 'Do you apply for all patients a fixed recall interval between two successive ROEs?' Fifty-one per cent of the GDPs (n=257) applied Fxs for all patients, generally for a period of 6 months. Ivs were applied by 49% (n=251) of GDPs, depending on the determination of specific patient characteristics. Logistic regression analysis showed that GDPs applying Fxs also used fixed periods between successive bitewing radiographs for all patients. Furthermore, dentists applying Ivs required more time to conduct an ROE, partly because of a more extensive periodontal screening. GDPs applying Fxs, adhered more to the opinion that a fixed recall regime (every 6 months, as existed before 1995) should be re-introduced, whereas the GDPs in support of Ivs were more in favour to support the opinion that the ROE is 'an excellent instrument for effective, individualized oral care'.

CONCLUSIONS

Dutch GDPs differ in the way they deal with the determination of recall interval frequency. These are also specific differences in performance and opinions regarding ROE. With the changing prevalence of oral diseases and the skewed distribution within populations, further research is advocated on consistent decision making to determine the most appropriate recall policy in preventing oral disease.

Oral health assessment in clinical practice: new perspectives on the need for a comprehensive and evidence based approach

This paper highlights one aspect of a presentation to be given at the BDA Conference and is written in the context of dentistry in primary care. Careful oral health assessment as a foundation to good treatment planning and quality dentistry is not new, but there are a number of important new perspectives emerging across countries and healthcare systems in terms of the content and role of such an assessment in modern dental practice.

The postural basis of malocclusion: a philosophical overview

Over the last 100 years, many theories have attempted to explain the cause of malocclusion. Most have stated that it is inherited, but, more recently, greater emphasis has been placed on the influence of the environment, especially the activity and the posture of the oral soft tissues. Unfortunately, it is not possible to measure long-term posture with any precision, and this has reduced its perceived importance. When some evidence is missing and much of the rest conflicting, there is merit in moving from the traditional "prove-it" attitude to philosophical reasoning to separate the probable from the improbable. We do not know to what extent posture and parafunction might be inherited, but there can be no doubt that facial and dental structures are, at times, strongly influenced by the soft tissues and that some malocclusions appear to have a postural basis. This article undertakes a philosophical examination of the conflicting strands of evidence that link oral posture with malocclusion, hoping to create a theory based solely on the restricted evidence that is broadly accepted by all sides in this age-old debate.

Evidence-based dentistry in German-language dental journals 1997-2003

The purpose of this systematic literature search was to evaluate how the evidence-based approach appears in German-language dental journals. All volumes of 28 dental journals published between 1997 and 2003 were searched by hand; for 15 of these journals, an additional electronic search was made. The focus of the search was all articles, editorials or letters to the Editor dealing with topics related to evidence-based dentistry (EBD)/medicine or using its terminology. Of the 1776 journal issues that were scrutinised, 368 relevant publications were found. After a low, albeit slightly increasing, number of pertinent contributions published between 1997 and 1999, there was a sharp rise in 2000 and 2001, culminating in 2003. Our findings indicate a rising awareness of the concept of EBD in the German-language dental literature. Nonetheless, its reception within the German-speaking dental community is still modest.

Research in primary dental care. Part 2: Developing a research question

The first step in planning and conducting any research is identifying the research question, that is a testable statement of the question which the research aims to answer. In this article three distinct types of research question are identified: Descriptive questions (for example Who? What? Where? When?); Questions of relationships (How are two or more things related?); Questions of comparison (often these questions will ask about cause and effect). Examples are given of each type of research question. The process of devising a research question is described, in particular searching for relevant information, and evaluating the quality of the information obtained. A list of useful resources is provided.

Orthodontic treatment for patients with clefts

Orthodontic strategies continue to evolve as new methods and treatment concepts more directly address the specific problems of patients who have clefts. By continual review of treatment outcomes and comparing outcomes with patients' problem lists and treatment objectives, clinicians will identify areas of treatment needing improvement and formulate hypotheses for future research.

Caries-Inhibiting Effect of Professional Fluoride Gel Application in Low-Caries Children Initially Aged 4.5–6.5 Years

It was the purpose of the study to investigate the caries-reducing effect of semi-annual professional fluoride gel application in a low-caries child population initially aged 4.5-6.5 years during a 4-year follow-up period. In a double-blind randomised controlled trial (n = 773) the effect of sodium fluoride gel on D3MFS and d3mfs was compared with a placebo gel. The mean caries reduction of professionally applied fluoride gel after 4 years in subjects with baseline caries experience D3MFS = 0 as well as d3mfs = 0 was 0.08 D3MFS (SE = 0.06) and 0.36 d3mfs (SE = 0.22). The prevented fraction for D3MFS and d3mfs was 26% (SE = 16%) and 20% (SE = 11%), respectively. It was concluded that in the investigated low-caries 4.5- to 6.5-year-olds, fluoride gel treatment showed a statistically significant (tested one-sided) caries-inhibiting effect on D3MFS, which was considered not clinically relevant, and no significant effect on d3mfs.

Understanding the jigsaw of evidence-based dentistry. 3. Implementation of research findings in clinical practice

Part one of this three-part series provided an overview of evidence-based dentistry (EBD), provided one definition of EBD and, having introduced the EBD matrix, concentrated on the research synthesis part of the jigsaw puzzle. Part two focused on the middle row of this puzzle, the dissemination of research results. This final article deals with perhaps the most vital but the most often overlooked element of the puzzle: implementation of research findings in clinical practice.

A Specialism of Primary Dental Care?

This opinion paper contends that a wide gap exists between the theory and practice of preventive dentistry. The reasons for this lie partly in the lack of recognition given to the potential for general dental practitioners (GDPs) to deliver health-focused care to their community of patients. This lack of recognition begins at undergraduate level and is also found among GDPs themselves. The creation of a specialism of primary dental care would help to bridge the gap between theory and practice, and help practitioners to create significantly improved levels of oral health within their respective communities.

Occlusion: Reflections on science and clinical reality

The last 50 years have seen progress in emphasizing scientific evidence as a basis for dental practice, including occlusal therapy. Although a proper understanding of the contributory role of occlusion to temporomandibular disorders should not be minimized, the importance of occlusion in other areas of dental education and practice should not be overlooked. The primary objective of this article is to discuss the nature of this problem as it relates to the duality of science and clinical reality in the evidence-based paradigm, information transfer, quality of evidence, clinical trials, and clinical aspects of occlusion. Some suggested solutions for the problem and thoughts on past and future perspectives of occlusion are expressed in context of inquiry.

A guide to systematic reviews

Systematic reviews have become widely used for evaluating evidence across all fields of biomedicine. The objective of a systematic review is to provide a comprehensive and contemporary appraisal of research using transparent methods whilst aiming to minimize bias. In essence, research methodology is employed in the conduct of the review. Such reviews are therefore fundamentally different from traditional 'narrative' review articles in their purpose and in their potential to aid clinical decision-making. This paper is a guide to the rationale and nature of systematic reviews and will provide a background to understanding their use in clinical practice.

Randomised controlled trials and publication trends in periodontal research during 1980-2000

OBJECTIVES

To study publication trends, as well as the number and proportion of randomised controlled trials covering different areas of periodontal research (RCT-Ps).

MATERIAL AND METHODS

The study was based on Medline searches (MeSH terms) for the period 1980- 2000. The RCT-Ps (n = 675) were examined for relevance for different areas of periodontal research, journals of publication, and the countries of origin.

RESULTS

In periodontal research the annual number of publications had increased from 162 in 1980 to 440 in 2000. Moreover, clinical trials in periodontal research (CT-Ps) had increased more than 10-fold, and RCT-Ps more than 15-fold. More than 4 out of 10 RCT-Ps covered the areas 'periodontal surgery' and 'gingivitis and plaque treatment or prevention'. More than 6 out of 10 RCT-Ps in total and more than 8 out of 10 RCT-Ps about 'periodontal surgery', were published in two different journals. U.S.A was the most common country of origin of RCT-Ps, contributing to almost 4 out of 10 RCT-Ps during 1988-2000.

CONCLUSION

The annual number of RCT-Ps increased substantially during 1980-2000, and a few clinical research areas predominated. Future research should give priority to areas where clinical evidence is scarce and where high-quality RCT-Ps are most needed.

Quality of RCTs in periodontology--a systematic review

Randomization, concealment of treatment allocation, blinding, and patient follow-up are key quality components of randomized controlled trials (RCTs). The objective of this study was to assess the quality of RCTs in periodontology using these evidence-based components. Following a detailed search, screening and quality assessments of RCTs were conducted in duplicate and independently. The results showed that although 91% of trials were described as randomised, adequate methods for randomization and allocation concealment were found in 17% and 7% of studies, respectively. Blinding was adequate for the caregiver in 17% and for the examiner in 55% of studies. A clear accounting of all participants was present in 56% of reports. This rigorous systematic review revealed that the quality of RCTs in periodontology, judged by their publications, frequently does not meet recommended standards. If this quality is reflected in actual study conduct, fundamental errors could have a significant impact on the outcomes of these trials.

Estimating MEDLINE's identification of randomized control trials in pediatric dentistry

The purpose of this study was to determine the number of randomized controlled trials in children from 1990-2000 in seven dental disciplines. Sensitive and specific MEDLINE search methodologies were used for upper and lower estimates, capture-recapture corrected those estimates, and hand evaluation refined the estimates. The data indicate that between 602 and 1737 trials were published, and the number per year doubled from 1990 to 2000. These results have implications for clinical decision making, the development of systematic reviews, insurance reimbursement, and teaching.

General dental practitioners' knowledge of and attitudes towards evidence based practice

AIMS

To assess general dental practitioners' understanding of, and attitudes towards, evidence based practice (EBP).

SUBJECTS

A random sample of general dental practitioners currently practising in the North West of England.

METHOD

A cross-sectional survey using self administered, structured, postal questionnaires in January 2001.

RESULTS

A majority of the respondents had some understanding of technical terms associated with EBP. Only 29% (60/204) could correctly define the term EBP. When faced with clinical uncertainties 60% (122/204) of general dental practitioners turned to friends and colleagues for help and advice. Eighty one percent of respondents were interested in finding out further information about EBP (165/204). Barriers to its use included a lack of available time and financial constraints.

CONCLUSIONS

EBP is not a concept that every dentist is familiar with, however, the general dental practitioners surveyed were enthusiastic and expressed a desire to find out more information on EBD. It appears to be the right time for an educational program targeted at GDPs to enhance their knowledge and use of EBD in everyday practice.

Links between anaesthetic modality and nerve damage during lower third molar surgery

OBJECTIVE

To investigate the relationships between eruption status, gender, social class, grade of operator, anaesthetic modality and nerve damage during third molar surgery.

DESIGN

Two centre prospective longitudinal study.

SETTING

The department of oral and maxillofacial surgery, University Hospital Birmingham NHS Trust and oral surgery outpatient clinics at Birmingham Dental Hospital.

SUBJECTS

A total of 391 patients had surgical removal of lower third molars. Sensory disturbance was recorded at one week post operatively. Patients with altered sensation were followed up at one month, three months and six months following surgery.

RESULTS

614 lower third molars in 391 patients were removed. Forty-six procedures (7.5%) were associated with altered sensation at one week with three procedures (0.49%) showing persistent symptoms at six months. Of these 46 nerve injuries, 26 (4.23%) involved the lingual nerve and 20 (3.25%) the inferior dental nerve (IDN). All three persistent sensations were IDN related. A logistic regression model found that the use ofa lingual retractor chi2 = 11.559, p = 0.003 was more significant than eruption status chi2 = 12.935, p = 0.007. There was no significant relationship between anaesthetic modality, age, social class, sex and seniority of operator.

CONCLUSIONS

There was no link between the choices of local or general anaesthesia and nerve damage during lower third molar removal when difficulty of surgery was taken into account.

Patient preferences and the measurement of utilities in the evaluation of dental technologies

Advances in life sciences that are predicted in the 21st century will present many challenges for health professionals and policy-makers. The major questions will be how to allocate resources to pay for costs of new technologies and who will best benefit from advances in new diagnostic and treatment methods. We review in this paper the concept of utility and how it can be applied and expanded to provide data to help health professionals make decisions that are preferred by patients and the public at large. Utility is a measure of people's well-being or preferences for outcomes. The measurement of utilities of a new diagnostic technology, for example, can be carried out with the use of simple methods that do not incorporate all of the uncertainties and potential outcomes associated with providing the test, or with more complex methods that can incorporate most uncertainties. This review describes and critiques the different measurement methods of utilities.

Medline search validity for randomised controlled trials in different areas of dental research

OBJECTIVE

To determine the validity of Medline searches for randomised controlled trials in dental research (RCT-Ds), using the medical subject headings (MeSH-terms).

DESIGN

The Medline database was searched for randomised controlled trials in dental research (RCT-Ds) published in 1999 and with MeSH-terms corresponding to different areas of dental research. All RCT-Ds were manually examined for relevance to the different areas of dental research and cross-tabulated against the Medline search results. The sensitivity, specificity, positive (precision) and negative predictive values, as well as the accuracy of the search results were calculated.

RESULTS

The highest validity in the Medline searches for RCT-Ds was seen for endodontics, followed by orthodontics, whereas the lowest validity was seen for pediatric dentistry and public health dentistry. For pediatric dentistry the MeSH-term searches had too low a sensitivity for adequate location of RCT-Ds.

CONCLUSIONS

MeSH-term searches on Medline are a useful tool for rapid location of RCT-Ds in most areas of dental research. However, there is a vast variation in the search validity. More refined search strategies are required to locate RCT-Ds in areas of dental research with low search validity.

Audit of a multidisciplinary approach to the care of children with unilateral and bilateral cleft lip and palate

Cleft lip and palate affects the child in many ways, particularly appearance, dental arch relationships, growth of the face, and speech development. The key to successful care is management in a multidisciplinary team adhering to a well-designed protocol, and careful audit of results. We present the intermediate outcome audit of 15 patients with complete bilateral and unilateral cleft lip and palate whose condition was managed in a multidisciplinary team according to a strict protocol. We give the results observations of operations of a single surgeon's functional primary surgery over a 6-year period in terms of dental arch relationships, cephalometric analyses, aesthetic assessments, and speech analysis. The results show good early facial growth, with dental arch relationships appropriate for the age and group; we found only minor speech discrepancies, with no patients requiring pharyngoplasty. The results show the importance of multidisciplinary management, the value of keeping to sound surgical protocols, and functional techniques in cleft lip and palate surgery. Our study includes the neglected group of children who have bilateral cleft lip and palate, and it conforms to the style of pan-European projects.

Trends in dental and medical research and relevance of randomized controlled trials to common activities in general dentistry

The aim was to study publication trends in dental and medical research as well as the proportion of randomized controlled trials in dental research (RCT-Ds) of relevance to common activities in general dentistry. The study was based on Medline searches, 1969 99 (MeSH terms). Data from Public Dental Services (county of Ostergötland, Sweden) were used to find the most common activities in the practice of general dentistry,. In dental research the annual number of publications had decreased from 5,900 in 1969 to 4,400 in 1999, corresponding to 9,100 and 14,000, respectively, in medical research. Clinical trials in dental research had increased to 7% and RCT-Ds to 5% of all dental research during 1969 99. In medicine, clinical trials and randomized controlled trials had increased to 2% and 1%, respectively. In dental and medical research, meta-analyses (MAs) totalled 0.1-0.2% in 1994 and 1999. One out of 200 dental research publications in 1979 99 was an RCT-D of relevance to the most common activities in general dentistry. These activities contributed to more than 80% of the dental care of children and adolescents and to more than 60% of the dental care of adults in 1999.

Assessing health outcomes after extraction of third molars: the postoperative symptom severity (PoSSe) scale

A postoperative symptom severity (PoSSe) scale was devised from questions commonly used in the clinical assessment of patients who have had third molars extracted, and divided into subscales corresponding to seven main adverse effects that had been identified in a previous study. Ninety-seven patients completed the 15-item questionnaire at one week, and 71 patients at four weeks, after extraction of impacted third molars. After statistical testing, four items were discarded and the final PoSSe scale achieved a high level of internal reliability. Patients' PoSSe scores were highly correlated with scales that measured six distinct health dimensions. The level of social functioning, together with the number of impacted teeth and number of painkillers taken, explained 62% of the variation in PoSSe scores between patients one week postoperatively. The PoSSe was more responsive than the Short Form 36-item Health Survey. In conclusion, we found the PoSSe Scale to be a reliable, valid and responsive measure of the severity of symptoms after extraction of third molars, and of the impact of those symptoms on patients' perceived health.

Dental science--reality of the evidence

Primary Dental Care publishes below the text of the Professor William Britto-Muthunayagam oration, which was delivered by the author earlier this year in Sri Lanka.