Developing a core outcome set for periodontal trials

Current status and implementation strategies of patient education in core outcome set development

OBJECTIVE

Patient participation is essential for Core Outcome Set (COS) development studies. Patient education during participation may help patients better express their views in COS studies. This study aimed to investigate the current status of patient participation and the specified educational information in COS studies.

METHODS

We conducted a systematic review of COS development studies. Information on patient participation in COS research, and especially details of patient education, was analyzed.

RESULTS

In total, 146 COS development studies were included in this review. Of these, 125 studies (85.6%) mentioned patient participation. Most studies did not provide explicit information on patient participation. Some studies mentioned recruiting patients, but ultimately, none of them responded. Six studies reported conducting patient education through workshops, creating patient forums, or providing videos and slides. However, these studies did not provide details on education. Twenty-three studies used the plain language to explain patient outcomes.

CONCLUSION

COS developers are increasingly focusing on patient participation. However, only a few COS studies have explicitly reported conducting measures related to patient education. Further patient education is necessary when they participate in the development of a new Core Outcome Set.

PRACTICE IMPLICATION

This article provides implementation strategies related to patient education for future COS development studies.

International Consensus on a Dental Antibiotic Stewardship Core Outcome Set

INTRODUCTION

Antibiotic resistance is a global health crisis. Ensuring responsible, appropriate use (stewardship) is an important for keeping antibiotics working as long as possible. Around 10% of antibiotics across health care are prescribed by oral health care professionals, with high rates of unnecessary use. To maximise the value from research to optimise antibiotic use in dentistry, this study developed international consensus on a core outcome set for dental antibiotic stewardship.

METHODS

Candidate outcomes were sourced from a literature review. International participants were recruited via professional bodies, patient organisations, and social media, with at least 30 dentists, academics, and patient contributors in total. Outcomes scored "critical for inclusion" by >70% of the participants (dentists, academics, and patients) after 2 Delphi rounds were included in the core outcome set following a final consensus meeting. The study protocol was registered with the COMET Initiative and published in BMC Trials.

RESULTS

A total of 33 participants from 15 countries, including 8 low- and middle-income countries, completed both rounds of the Delphi study. Antibiotic use outcomes (eg, appropriateness of prescribing), adverse or poor outcomes (eg, complications from disease progression), and a patient-reported outcome were included in the final, agreed core set. Outcomes relating to quality, time, and cost were not included.

CONCLUSIONS

This core outcome set for dental antibiotic stewardship represents the minimum which future studies of antibiotic stewardship in dentistry should report. By supporting researchers to design and report their studies in a way meaningful to multiple stakeholders and enabling international comparisons, the oral health profession's contribution to global efforts to tackle antibiotic resistance can be further improved.

The importance of establishing a core outcome set for endodontic clinical trials and outcomes studies

Endodontic therapy aims to preserve teeth by preventing and treating apical disease, therefore, evaluation of treatment outcome in clinical trials and outcomes studies should effectively assess if it achieves these aims. Traditionally, treatment outcomes have been reported by clinicians after history and clinical examination in what is known as clinician-reported outcomes (CROs). Much less commonly employed however, are patient-reported outcomes (PROs) in which patients directly report on their condition. Endodontic treatment outcome reporting is evolving from a focus on CROs to increasing consideration for patient and disease-focused outcomes, with different criteria being proposed for assessment of treatment outcomes. Unfortunately, this has led to considerable variability and a lack of consensus on the definition, appropriate measurement and reporting of these outcomes. Heterogeneity in outcome reporting in clinical research provides a significant major barrier to conduct meta-analysis, guidelines development, clinical decision making, and ultimately affecting patient care. These effects could, however, be reduced by the establishment of a core outcome set (COS) in endodontics, which is defined as an agreed, standardized set of outcomes that should be included, measured and reported as a minimum in all trials and outcome studies. COS development is a regulated and validated process requiring involvement of appropriate stakeholders as well as a rigorous methodology. To date, COS has been developed for the management of traumatic dental injuries, orthodontic and periodontal treatment and is currently being developed for endodontic treatment. The aim of this review is to discuss the importance of COS in endodontics with focus on the evidence for and impact of heterogeneity in reporting endodontic treatment outcomes. An overview of an ongoing process for development of COS for different endodontic treatment modalities will also be provided.

Outcomes of periodontal therapy: Strengthening the relevance of research to patients. A co-created review

Periodontitis is a long-term condition affecting up to half of the population globally and causing significant impacts on life quality. Successful management depends on taking life-long ownership of the condition by those affected. There is a wealth of research to inform on management options. However, most of the research has been designed by professional experts with outcomes to gauge benefits and harms based on parameters that inform on the disease process but which might not be informative to support decision-making in people with lived experience (PWLE) of periodontal ill-health (including both patients and carers). The importance of relevant outcomes is highlighted in the concept of the "expert patient" which aims to strengthen the capacity of PWLE to make health-care choices that are important for them, elements of which are likely to be already familiar to many clinicians delivering periodontal health care. Therefore, the voice and collaboration of PWLE in research are recognised as crucial to developing high quality, relevant evidence especially for long-term conditions. In this paper, we review what is known about the relevance of treatment outcomes to PWLE. We also examine the degree to which PWLE have been involved in identifying outcomes that are important to them as well as the diversity and therefore representativeness of PWLE recruited for studies. We consider why having more relevant outcomes could enhance the expertise of PWLE in managing their periodontitis. We then conclude with key learnings from our review which we hope will encourage more rapid development of these initiatives in periodontology for the benefit of global health and wellbeing.

Evolution and development of methodologies in social and behavioural science research in relation to oral health

The aim of this introductory paper is to provide an overview of key methodological developments in social and behavioural research in oral health. In the first section, we provide a brief historical perspective on research in the field. In the second section, we outline key methodological issues and introduce the seven papers in the theme. Conceptual models can contextualize research findings and address the 'why' and 'how' instead of 'what' and 'how many'. Many models exist, albeit they need to be evaluated (and adapted) for use in oral health research and in specific settings. The increasing availability of big data can facilitate this with data linkage. Through data linkage, it is possible to explore and understand in a broader capacity the array of factors that influence oral health outcomes and how oral health can influences other factors. With advances in statistical approaches, it is feasible to consider casual inferences and to quantify these effects. There is a need for not only individual efforts to embrace causal inference research but also systematic and structural changes in the field to yield substantial results. The value of qualitative research in co-producing knowledge with and from human participants in addressing 'the how' and 'the why' factors is also key. There have been calls to employ more sophisticated qualitative methods together with mixed methods approaches as ways of helping to address the complex or Wicked Problems in population oral health. In the final section, we outline possible future methodological directions in social and behavioural oral health research including participatory approaches and the development of core outcome sets. Our overriding goal in the paper is to facilitate a critical debate in relation to methodological issues which can be used to improve understanding and generate knowledge in population oral health and that this, in turn, will help inform oral health policy and practices.

Periodontal health and patient-reported outcomes: A longitudinal analysis of data from non-specialist practice settings

AIM

To explore the associations between periodontal health and patient-reported outcomes (PROs), accounting for changes over time, in a large, non-specialist dental practice patient cohort.

MATERIALS AND METHODS

This longitudinal study used data from 13,162 dentate patients, collected by 162 dentists at routine appointments between May 2013 and April 2020, in 238 non-specialist dental practices across the United Kingdom. Dentists collected data, as part of routine clinical care, on periodontal probing pocket depths, alveolar bone loss, bleeding on probing, as well as a range of covariates. Patients inputted data on outcomes (oral pain/discomfort, dietary restrictions, and dental appearance). Mixed-effects logistic regression analysis was used to investigate the associations between periodontal health and PROs. Models accounted for clustering at the patient and dentist level and were adjusted for time and variables which were thought to confound these associations.

RESULTS

The odds of all PROs tended to increase with worsening periodontal parameters. For example, the odds of reporting pain in the worst periodontal health category were 1.99 (95% confidence interval: 1.57-2.53) times higher than in the best periodontal health category.

CONCLUSIONS

This study confirms, using a large longitudinal dataset from a unique non-specialist setting, the associations between poorer periodontal health and poorer PROs.

Retrospective exploratory study of smoking status and e-cigarette use with response to non-surgical periodontal therapy

BACKGROUND

To compare periodontal treatment responses in electronic cigarette (e-cigarette) users, non-smokers, former and current smokers.

METHODS

In this retrospective clinical study, 220 patients with periodontitis were seen for baseline periodontal charting, professional-mechanical-plaque-removal (PMPR) and re-evaluation by postgraduate students. Sixty of these patients were former smokers, twenty were former smokers now using e-cigarettes, twenty current smokers, while all others (n = 120) were non-smokers. Effects of smoking status and treatment duration on clinical outcomes were analyzed by linear models using generalized least squares adjusted for known confounders. The primary outcome was "need for surgery" defined as number of sextants with ≥2 non-adjacent sites of probing depths (PD) ≥5 mm.

RESULTS

Compared with non-smokers, e-cigarette users had a less favorable treatment response after PMPR. This included statistically significant increased "need for surgery", as well as increased number of sextants with PD ≥5 mm, number of sites with PD >5 mm and mean PD. There were no statistically significant differences between e-cigarette users and current smokers. Former smokers responded statistically significantly better than e-cigarette users for the primary outcome as well as for the number of sextants and sites with PD ≥5 mm and mean PD.

CONCLUSIONS

Overall, e-cigarette users had a statistically significantly less favorable response to PMPR than non-smokers; their response was not statistically significantly different to those of current smokers. This, however, needs to be validated with further research in prospective clinical and observational studies in different populations.

Bone preservation or augmentation simultaneous with or prior to dental implant placement: A systematic review of outcomes and outcome measures used in clinical trials in the last 10 years

AIM

To evaluate outcome measures and methods of assessment in clinical studies on bone augmentation/preservation procedures for the placement of dental implants.

MATERIALS AND METHODS

A systematic search was performed on three databases from January 2011 to April 2021 to identify clinical studies reporting on any type of bone augmentation/preservation procedure. The outcomes that have been used to assess efficacy or performance in each study were registered and assigned to different domains (group of outcomes). The review followed the Preferred Reporting Items for Systematic Review and Meta-Analyses statement.

RESULTS

Seven-hundred and eighty-three publications were included. Only 81.8% of the papers had a clear definition of their primary outcome. The rate of complications (59.3%), implant survival (58.2%), 3D radiographic bone gain/change (30%), marginal bone level (MBL; 29%), and histological outcomes (25.5%) were the most frequently reported outcome domains. The most commonly used primary outcome was 3D radiographic bone gain/change (25.8%), followed by implant survival (13.0%). Patient-reported outcome measures (PROMs) were reported in 15.7% of studies. Differences in the reported outcomes were observed among different types of bone preservation/augmentation interventions (i.e., alveolar ridge preservation, immediate implants, horizontal and/or vertical ridge augmentation, and sinus floor augmentation).

CONCLUSION

Within the past decade, great heterogeneity was observed among the outcomes considered in studies evaluating bone preservation/augmentation procedures. Three-dimensional radiographic bone gain/change was the most routinely reported main outcome variable, while PROMs were rarely reported.

Bone preservation or augmentation simultaneous with or prior to dental implant placement: A systematic review of outcomes and outcome measures used in clinical trials in the last 10 years

AIM

To evaluate outcome measures and methods of assessment in clinical studies on bone augmentation/preservation procedures for the placement of dental implants.

MATERIALS AND METHODS

A systematic search was performed on three databases from January 2011 to April 2021 to identify clinical studies reporting on any type of bone augmentation/preservation procedure. The outcomes that have been used to assess efficacy or performance in each study were registered and assigned to different domains (group of outcomes). The review followed the Preferred Reporting Items for Systematic Review and Meta-Analyses statement.

RESULTS

Seven-hundred and eighty-three publications were included. Only 81.8% of the papers had a clear definition of their primary outcome. The rate of complications (59.3%), implant survival (58.2%), 3D radiographic bone gain/change (30%), marginal bone level (MBL; 29%), and histological outcomes (25.5%) were the most frequently reported outcome domains. The most commonly used primary outcome was 3D radiographic bone gain/change (25.8%), followed by implant survival (13.0%). Patient-reported outcome measures (PROMs) were reported in 15.7% of studies. Differences in the reported outcomes were observed among different types of bone preservation/augmentation interventions (i.e., alveolar ridge preservation, immediate implants, horizontal and/or vertical ridge augmentation, and sinus floor augmentation).

CONCLUSION

Within the past decade, great heterogeneity was observed among the outcomes considered in studies evaluating bone preservation/augmentation procedures. Three-dimensional radiographic bone gain/change was the most routinely reported main outcome variable, while PROMs were rarely reported.