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Chambrone L, Garcia-Valenzuela FS, Avila-Ortiz G. Errors and complications in clinical periodontal practice due to methodologic bias and bad interpretation of the evidence. Periodontol 2000 2023; 92:373-381. [PMID: 36604793 DOI: 10.1111/prd.12475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 08/01/2022] [Accepted: 08/21/2022] [Indexed: 01/07/2023]
Abstract
Different types of errors and complications may arise during and after the execution of periodontal or implant-related procedures. Some of the most relevant, although also controversial, and less commented, causative agents of errors and complications are methodological biases and bad interpretation of the evidence. Proper assessment of the literature requires of solid clinical knowledge combined with a systematic approach built on the recognition of common methodological biases and the avoidance of interpretive errors to critically retrieve, dissect, and judiciously apply available information for the promotion of periodontal and peri-implant health. This review addresses common types of methodological bias and interpretive errors that can alter the reader's perceptions on the real effect and potential ramifications of the reported outcomes of a given therapeutic approach due to bad interpretation of the available evidence: (1) types of methodological biases; (2) spin and interpretive bias; (3) interpretation pitfalls when assessing the evidence (4) choice of relevant endpoints to answer the question(s) of interest; and (5) balance between statistical significance and clinical relevance.
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Affiliation(s)
- Leandro Chambrone
- Evidence-Based Hub, Centro de Investigação Interdisciplinar Egas Moniz (CiiEM), Egas Moniz, CRL, Monte de Caparica, Portugal
- Unit of Basic Oral Investigation (UIBO), School of Dentistry, Universidad El Bosque, Bogota, Colombia
- Department of Periodontics, School of Dental Medicine, The University of Pennsylvania, Pennsylvania, Philadelphia, USA
| | | | - Gustavo Avila-Ortiz
- Private Practice, Atelier Dental, Madrid, Spain
- Department of Oral Medicine, Infection, and Immunity, Harvard School of Dental Medicine, Massachusetts, Boston, USA
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Tan OL, Safii SH, Razali M. Clinical Efficacy of Single Application Local Drug Delivery and Adjunctive Agents in Nonsurgical Periodontal Therapy: A Systematic Review and Network Meta-Analysis. Pharmaceutics 2020; 12:E1086. [PMID: 33198248 PMCID: PMC7698182 DOI: 10.3390/pharmaceutics12111086] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 11/09/2020] [Accepted: 11/10/2020] [Indexed: 12/29/2022] Open
Abstract
This review aimed to rank the clinical efficacy of commercially available single-application local drug delivery and adjunctive agents (LDAs) compared with subgingival mechanical debridement (SMD) in nonsurgical periodontal therapy (NSPT). Randomized controlled clinical trials that compared LDAs against SMD alone or with placebo in adults (aged at least 18 years) diagnosed with periodontitis with a minimum of 6 months follow-up were included. A frequentist approach to random-effects network meta-analysis was implemented. The efficacies of the LDAs measured by probing pocket depth (PPD) reduction and clinical attachment level (CAL) gain were reported as mean difference (MD) with 95% confidence intervals (CIs). The treatments were ranked according to their P-score. Four network meta-analyses suggested that sulfonic/sulfuric acid gel (PPD MD -1.13 mm, 95% CI -1.74 to -0.53, P-score 0.91; CAL MD -1.09 mm, 95% CI -1.58 to -0.61, P-score 0.95) and doxycycline hyclate gel (PPD MD -0.90 mm, 95% CI -1.50 to -0.30, P-score 0.93; CAL MD -0.84 mm, 95% CI -1.40 to -0.28, P-score 0.92) were the most effective in reducing PPD and gaining CAL in split-mouth and parallel studies, respectively (moderate certainty of evidence). LDAs have differing efficacies, but they present with possible clinical significance over SMD alone in NSPT.
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Affiliation(s)
- Oi Leng Tan
- Centre for Restorative Dentistry, Unit of Periodontology, Faculty of Dentistry, National University of Malaysia, Jalan Raja Muda Abdul Aziz, Kuala Lumpur 50300, Malaysia;
| | - Syarida Hasnur Safii
- Department of Restorative Dentistry, Faculty of Dentistry, University of Malaya, Kuala Lumpur 50603, Malaysia;
| | - Masfueh Razali
- Centre for Restorative Dentistry, Unit of Periodontology, Faculty of Dentistry, National University of Malaysia, Jalan Raja Muda Abdul Aziz, Kuala Lumpur 50300, Malaysia;
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Randomized Clinical Trials in Pediatric Dentistry: Application of Evidence-Based Dentistry through the CONSORT Statement. J Clin Pediatr Dent 2019; 43:219-230. [PMID: 31094627 DOI: 10.17796/1053-4625-43.4.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
In order to include appropriate informed decisions on dental therapeutic or preventive procedures in children, Pediatric Dentists should apply the fundamentals of "Evidence-Based Dentistry" (EBD). This oral health approach assists clinicians in understanding and applying the most relevant research published on evidence in the clinical setting when treating their patients. One of the crucial steps of EBD is to critically appraise and use the primary articles about therapy or prevention, namely, Randomized Clinical Trials (RCT), the study design that best addresses the questions related with these clinical areas. The aim of the present paper was to provide the basic concepts and an example of how to critically read and understand articles on RCT studies in Pediatric Dentistry employing the CONSORT statement, a process that involves assessing the reliability of results, risk of bias (internal validity), and applicability of reported clinical findings (external validity).
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Preus HR, Gjermo P, Baelum V. A double-masked Randomized Clinical Trial (RCT) comparing four periodontitis treatment strategies: 5-year clinical results. J Clin Periodontol 2017; 44:1029-1038. [DOI: 10.1111/jcpe.12793] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/06/2017] [Indexed: 01/21/2023]
Affiliation(s)
- Hans R. Preus
- Department of Periodontology; Institute of Clinical Odontology; Faculty of Dentistry; University of Oslo; Oslo Norway
| | - Per Gjermo
- Department of Periodontology; Institute of Clinical Odontology; Faculty of Dentistry; University of Oslo; Oslo Norway
| | - Vibeke Baelum
- Department of Dentistry and Oral Health; Aarhus University; Aarhus Denmark
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Fundamentals in Biostatistics for Research in Pediatric Dentistry: Part I - Basic Concepts. J Clin Pediatr Dent 2017; 41:87-94. [PMID: 28288291 DOI: 10.17796/1053-4628-41.2.87] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The purpose of this report was to provide the reader with some basic concepts in order to better understand the significance and reliability of the results of any article on Pediatric Dentistry. Currently, Pediatric Dentists need the best evidence available in the literature on which to base their diagnoses and treatment decisions for the children's oral care. Basic understanding of Biostatistics plays an important role during the entire Evidence-Based Dentistry (EBD) process. This report describes Biostatistics fundamentals in order to introduce the basic concepts used in statistics, such as summary measures, estimation, hypothesis testing, effect size, level of significance, p value, confidence intervals, etc., which are available to Pediatric Dentists interested in reading or designing original clinical or epidemiological studies.
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Goh EX, Tan KS, Chan YH, Lim LP. Effects of root debridement and adjunctive photodynamic therapy in residual pockets of patients on supportive periodontal therapy: A randomized split-mouth trial. Photodiagnosis Photodyn Ther 2017; 18:342-348. [PMID: 28366818 DOI: 10.1016/j.pdpdt.2017.03.017] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2017] [Revised: 03/28/2017] [Accepted: 03/29/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND The study aims to compare the effects of adjunctive photodynamic therapy (PDT) with scaling and root debridement alone on periodontal parameters and inflammatory cytokines in residual pockets of patients undergoing maintenance therapy. METHODS 27 subjects, each with at least 2 residual pockets ≥5mm, were recruited for this randomized, split-mouth controlled trial, providing total of 72 sites. Probing pocket depth (PPD), recession, clinical attachment loss (CAL), plaque and bleeding on probing of all sites were examined at baseline, 3 and 6 months. Gingival crevicular fluids (GCFs) were collected to determine levels of IL-1β, IL-6, IL-8, TNF-α and MMP-8 via enzyme-linked immunosorbent assay. At baseline, all sites received subgingival instrumentation and polishing. In addition, test sites received a single application of PDT using Fotosan® with toluidine blue O solution photosensitizer. At 3 and 6 months, site level analysis was performed for changes in clinical parameters and cytokine level. RESULTS Based on mixed model analysis, at 3 months, test sites showed significant reduction in CAL (p=0.016) and PPD (p=0.027) (from 6.14±0.28mm to 5.49±0.20mm and 5.42±0.16mm to 4.65±0.18mm respectively) compared to control sites (from 6.32±0.24mm to 6.08±0.17mm and 5.32±0.13mm to 5.15±0.15mm respectively). At 6 months, these differences were no longer significant (p=0.510). Adjunctive PDT did not offer additional reduction in levels of GCF cytokines. CONCLUSIONS A single application of PDT to residual pockets provided a modest improvement of CAL and PPD over 3 months. Application of adjunctive PDT may lead to faster resolution of residual pockets and may be recommended for periodontal patients with slower healing capacity.
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Affiliation(s)
- Edwin X Goh
- Discipline of Periodontology, Faculty of Dentistry, National University of Singapore, Republic of Singapore.
| | - Kai Soo Tan
- Discipline of Oral Sciences, Faculty of Dentistry, National University of Singapore, Republic of Singapore.
| | - Yiong Huak Chan
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Republic of Singapore.
| | - Lum Peng Lim
- Discipline of Periodontology, Faculty of Dentistry, National University of Singapore, Republic of Singapore.
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Chambrone L, Armitage GC. Commentary: Statistical Significance Versus Clinical Relevance in Periodontal Research: Implications for Clinical Practice. J Periodontol 2016; 87:613-6. [DOI: 10.1902/jop.2016.150554] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Baelum V, López R. Defining and predicting outcomes of non-surgical periodontal treatment: a 1-yr follow-up study. Eur J Oral Sci 2015; 124:33-44. [PMID: 26714428 DOI: 10.1111/eos.12240] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2015] [Indexed: 12/28/2022]
Abstract
This study reports on 1-yr outcomes of non-surgical periodontal therapy and compares predictive models resulting from different definitions of treatment success. A total of 149 participants, 30-70 yr of age, provided clinical periodontal data and data on sociodemographic status, health status, symptoms, and oral health-care behaviors at baseline. One week later, clinical attachment level and probing pocket depth were recorded again in 148 patients. Participants underwent non-surgical periodontal therapy, including scaling and root planing, during three to four clinical sessions. Three and 12 months later, clinical attachment level, probing pocket depth, and bleeding on probing (BOP) were recorded in 141 and 137 participants, respectively. Using test-retest data, patients were classified as having 'downhill', 'stable', or 'improved' results on three clinical attachment level and three probing pocket depth outcomes, and their classification was found to vary considerably according to outcome. Although the predictors of treatment outcome varied depending on the variable chosen to represent the treatment outcome, some predictors were more commonly noted as predicting improvement, namely a high baseline percentage of sites with subgingival calculus and the presence of suppuration at baseline. The latter was, however, also predictive for tooth loss during the study. Our findings underline the need for uniformity in defining the outcomes in trials of periodontal therapy.
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Affiliation(s)
- Vibeke Baelum
- Department of Dentistry, Section for Oral Epidemiology & Public Health, Aarhus University, Aarhus C, Denmark
| | - Rodrigo López
- Department of Dentistry, Section for Periodontology, Health, Aarhus University, Aarhus C, Denmark
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Corraini P, Lopez R, Vaeth M. Implications of less-than-perfect reliability of clinical parameters for the misclassification of periodontitis. Community Dent Oral Epidemiol 2015; 43:183-92. [DOI: 10.1111/cdoe.12142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Accepted: 12/14/2014] [Indexed: 11/28/2022]
Affiliation(s)
- Priscila Corraini
- Department of Dentistry; Section of Periodontology; Health; Aarhus University; Aarhus Denmark
- Department of Clinical Epidemiology; Aarhus University; Aarhus Denmark
| | - Rodrigo Lopez
- Department of Dentistry; Section of Periodontology; Health; Aarhus University; Aarhus Denmark
| | - Michael Vaeth
- Department of Public Health; Section of Biostatistics; Health; Aarhus University; Aarhus Denmark
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Zeng J, Williams SM, Fletcher DJ, Cameron CM, Broadbent JM, Shearer DM, Thomson WM. Reexamining the Association Between Smoking and Periodontitis in the Dunedin Study With an Enhanced Analytical Approach. J Periodontol 2014; 85:1390-7. [DOI: 10.1902/jop.2014.130577] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Finoti LS, Corbi SCT, Anovazzi G, Teixeira SRL, Capela MV, Tanaka MH, Kim YJ, Orrico SRP, Cirelli JA, Mayer MPA, Scarel-Caminaga RM. Pathogen levels and clinical response to periodontal treatment in patients with Interleukin 8 haplotypes. Pathog Dis 2013; 69:21-28. [PMID: 23821559 DOI: 10.1111/2049-632x.12062] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Revised: 06/14/2013] [Accepted: 06/15/2013] [Indexed: 11/30/2022] Open
Abstract
The aim of this study was to investigate the effect of non-surgical treatment of periodontitis on the levels of periodontopathogens and clinical parameters in patients with different genetic backgrounds produced by polymorphisms in the Interleukin ( IL8) gene. Thirty patients grouped according to IL8 ATC/TTC or AGT/TTC haplotypes were submitted to non-surgical periodontal treatment. Levels of Porphyromonas gingivalis, Tannerella forsythia, and Treponema denticola were determined in 240 subgingival plaque samples by qPCR. The association between IL8 haplotypes and the levels of periodontopathogens and clinical parameters was investigated by multilevel analysis accounting for the clustering of diseased sites analyzed within patients. It was observed that neither levels of periodontopathogens nor non-surgical treatment was associated with the IL8 haplotype. The clinical parameters after periodontal treatment were similar in diseased and healthy sites, independently of the IL8 haplotype. Nonetheless, in the same period, diseased sites of AGT/TTC patients harbored higher levels of P. gingivalis, T. denticola, T. forsythia, and red complex than those of ATC/TTC patients. However, the non-surgical periodontal therapy decreased the levels of these periodontopathogens and of the tested clinical parameters of diseased sites in both groups. Non-surgical therapy is equally effective in improving clinical parameters and decreasing the levels of periodontopathogens, independent of the genotype groups produced by the IL8 haplotype.
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Affiliation(s)
- Livia S Finoti
- Department of Oral Diagnosis and Surgery, School of Dentistry at Araraquara, UNESP- Universidade Estadual Paulista, Araraquara, SP, Brazil
| | - Sâmia C T Corbi
- Department of Oral Diagnosis and Surgery, School of Dentistry at Araraquara, UNESP- Universidade Estadual Paulista, Araraquara, SP, Brazil
| | - Giovana Anovazzi
- Department of Oral Diagnosis and Surgery, School of Dentistry at Araraquara, UNESP- Universidade Estadual Paulista, Araraquara, SP, Brazil
| | - Silvia R L Teixeira
- Department of Microbiology, Institute of Biomedical Sciences, University of São Paulo, São Paulo, Brazil
| | - Marisa V Capela
- Department of Physical Chemistry, Institute of Chemistry at Araraquara, UNESP- Universidade Estadual Paulista, Araraquara, SP, Brazil
| | - Márcia H Tanaka
- Department of Morphology, School of Dentistry at Araraquara, UNESP- Universidade Estadual Paulista, Araraquara, SP, Brazil
| | - Yeon J Kim
- Department of Oral Diagnosis and Surgery, School of Dentistry at Araraquara, UNESP- Universidade Estadual Paulista, Araraquara, SP, Brazil
| | - Silvana R P Orrico
- Department of Oral Diagnosis and Surgery, School of Dentistry at Araraquara, UNESP- Universidade Estadual Paulista, Araraquara, SP, Brazil
| | - Joni A Cirelli
- Department of Oral Diagnosis and Surgery, School of Dentistry at Araraquara, UNESP- Universidade Estadual Paulista, Araraquara, SP, Brazil
| | - Marcia P A Mayer
- Department of Microbiology, Institute of Biomedical Sciences, University of São Paulo, São Paulo, Brazil
| | - Raquel M Scarel-Caminaga
- Department of Morphology, School of Dentistry at Araraquara, UNESP- Universidade Estadual Paulista, Araraquara, SP, Brazil
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Avula H. Periodontal Research: Basics and beyond - Part II (Ethical issues, sampling, outcome measures and bias). J Indian Soc Periodontol 2013; 17:571-6. [PMID: 24174747 PMCID: PMC3808008 DOI: 10.4103/0972-124x.119282] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2012] [Accepted: 08/11/2013] [Indexed: 11/04/2022] Open
Abstract
A good research beginning refers to formulating a well-defined research question, developing a hypothesis and choosing an appropriate study design. The first part of the review series has discussed these issues in depth and this paper intends to throw light on other issues pertaining to the implementation of research. These include the various ethical norms and standards in human experimentation, the eligibility criteria for the participants, sampling methods and sample size calculation, various outcome measures that need to be defined and the biases that can be introduced in research.
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Affiliation(s)
- Haritha Avula
- Department of Periodontics, Sri Sai College of Dental Surgery, Vikarabad, Andhra Pradesh, India
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Abstract
As periodontal researchers and clinicians, we are challenged every day to make decisions relating to the clinical management of our patients and about how best to conduct clinical periodontal research. This volume of Periodontology 2000 addresses some of the critical issues in contemporary clinical periodontics and periodontal research that are of direct relevance to clinicians, researchers, teachers and students. The 11 review articles in this volume of Periodontology 2000 focus on aspects of periodontal research methodology and clinical periodontology. In terms of research methodology, the articles aim to inform the reader on topics relating to randomized controlled trials in periodontal research, evidence-based dentistry, calibration of clinical examiners and statistics relevant to periodontal research. The clinical periodontology articles address issues relating to decisions on retaining periodontally compromised teeth or replacing them with implants, periodontal management in the patient with osteoporosis, surgical approaches for root coverage and the emerging science of advanced regenerative technologies, including the use of stem cells, for periodontal regeneration. It is hoped that these critical reviews will address many of the dilemmas that confront us on a regular basis and provide practical guidance to those engaged in both clinical periodontology and clinical periodontal research.
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