Is the use of tobacco products, especially electronic nicotine delivery systems (ENDS), associated with the incidence of oral health outcomes among US adults?

DESIGN

Cohort study.

SAMPLE SELECTION

Data were pooled from wave (W) 1 to W5 (2013-2019) of the Population Assessment of Tobacco and Health Study Restricted-Use Files. The W1 cohort respondents were interviewed at all five waves who were aged 18 years and older without a lifetime history of each of the six oral health outcomes (gum disease, precancerous oral lesions, bone loss around teeth, bleeding after brushing or flossing, loose teeth, number of teeth removed because of tooth decay or gum disease).

DATA ANALYSIS

Data analysis was performed from October 2021 to September 2022. To assess associations between current established tobacco use and incidence of adverse oral health outcomes at the next wave, adjusted hazard ratios (AHRs) and 95% CIs were calculated using Cox proportional hazards models.

RESULTS

Cigarette smoking was positively associated with incidence of gum disease diagnosis (AHR, 1.33; 95% CI, 1.11-1.60), loose teeth (AHR, 1.35; 95% CI, 1.05-1.75), and one or more teeth removed (AHR, 1.43; 95% CI, 1.18-1.74). Smoking any cigars was positively associated with incidence of precancerous oral lesions (AHR, 2.18; 95% CI, 1.38-3.43). Hookah smoking was positively associated with incidence of gum disease diagnosis (AHR, 1.78; 95% CI, 1.20-2.63). Use of electronic nicotine delivery systems (ENDS) was positively associated with incidence of bleeding after brushing or flossing (AHR, 1.27; 95% CI, 1.04-1.54). Snus and smokeless tobacco (excluding snus) were not significantly associated with incidence of gum disease diagnosis or precancerous oral lesions.

CONCLUSIONS

This cohort study confirmed associations of current combustible tobacco use with incidence of adverse oral health outcomes. It also showed an association between current ENDS use and incidence of bleeding after brushing or flossing.

Modelling a Consultant Workforce for the United Kingdom: needs-based planning for Dental Public Health

OBJECTIVE

To develop a needs-based workforce planning model to explore specialist workforce capacity and capability for the effective, efficient, and safe provision of services in the United Kingdom (UK); and test the model using Dental Public Health (DPH).

BASIC RESEARCH DESIGN

Data from a national workforce survey, national audit, and specialty workshops in 2020 and 2021 set the parameters for a safe effective DPH workforce. A working group drawing on external expertise, developed a conceptual workforce model which informed the mathematical modelling, taking a Markovian approach. The latter enabled the consideration of possible scenarios relating to workforce development. It involved exploration of capacity within each career stage in DPH across a time horizon of 15 years. Workforce capacity requirements were calculated, informed by past principles.

RESULTS

Currently an estimated 100 whole time equivalent (WTE) specialists are required to provide a realistic basic capacity nationally for DPH across the UK given the range of organisations, population growth, complexity and diversity of specialty roles. In February 2022 the specialty had 53.55 WTE academic/service consultants, thus a significant gap. The modelling evidence suggests a reduction in DPH specialist capacity towards a steady state in line with the current rate of training, recruitment and retention. The scenario involving increasing training numbers and drawing on other sources of public health trained dentists whilst retaining expertise within DPH has the potential to build workforce capacity.

CONCLUSIONS

Current capacity is below basic requirements and approaching 'steady state'. Retention and innovative capacity building are required to secure and safeguard the provision of specialist DPH services to meet the needs of the UK health and care systems.

Effect of implant rehabilitation on oral health-related quality of life with three different implant strategies

Design Non-randomised controlled trial.Case selection Patients requiring dental implants were recruited from a private dental surgery in Spain. According to the clinical diagnosis and patient preference, patients were assigned to one of the following three treatment protocols: the conventional treatment (CGCL), in which implants were inserted after flap elevation without guiding templates; the guided surgery/conventional loading group (GSCL); and the guided surgery/immediate loading group (GSIL).Data analysis An oral examination and a questionnaire-based interview were carried out at baseline and three months after the delivery of the definitive prosthetic rehabilitation. Two complementary indicators, Oral Impacts on Daily Performances (OIDP) and Oral Satisfaction Scale (OSS) were used to assess the changes in oral health-related quality of life (OHQoL). Paired t-tests were used to compare the within-subject change scores. ANOVA tests were used to compare quantitative variables between groups. Chi-square tests were used to compare the distribution of data between groups. Effect size was used to assess the relative responsiveness of different health indicators and to compare the amount of change resulting from different treatment protocols. A forward stepwise logistic regression analysis was performed to predict the risk of having impact after treatment.Results A total of 104 patients were recruited: CGCL (n = 40), GSCL (n = 35) and GSIL (n = 29). At baseline, the OHQoL was significantly greater among those assigned to CGCL (2.4 ± 1.3) than those assigned to GSCL (3.3 ± 1.3), which were both greater than those patients assigned to GSIL (4.6 ± 2.0). After implant therapy, the oral wellbeing was significantly better than at baseline, and patient satisfaction was greater when the implants were loaded immediately (8.7 ± 1.1) than if the prosthetic rehabilitation was delayed (8.3 ± 1.1). In the GSIL group, the effect size of the OIDP exceeded the threshold value of 0.8 for all of the OIDP domains and for the total OIDP score and patient satisfaction.Conclusions A global improvement in the OHQoL scores and patient satisfaction was observed after implant therapy, but the change was marked greater in the GSIL group.

The Truth about Sugar

Sugars are used by the industry to enhance the attractiveness of foods and drinks. These added sugars, or 'free sugars', are not easily identified in food or drink labels. Certain manufactured foods and drinks with 'safe' names, such as dried fruit and fruit juice, still contain free sugars and can be confusing. Guidance states that daily consumption of free sugars should be less than 10% of total energy intake (no more than 5% in the UK). However, it is found that both tooth decay and obesity are associated with consumption of free sugars in large quantities and at inappropriate times.

WITHDRAWN: Ceramic inlays for restoring posterior teeth

Withdrawn as the review has been superseded by a more up to date version of a Cochrane review of the same title.

The editorial group responsible for this previously published document have withdrawn it from publication.

Fluoridated milk for preventing dental caries

BACKGROUND

Dental caries remains a major public health problem in most industrialised countries, affecting 60% to 90% of schoolchildren and the vast majority of adults. Milk may provide a relatively cost-effective vehicle for fluoride delivery in the prevention of dental caries. This is an update of a Cochrane review first published in 2005.

OBJECTIVES

To assess the effects of milk fluoridation for preventing dental caries at a community level.

SEARCH METHODS

We searched the Cochrane Oral Health Group Trials Register (inception to November 2014), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2014, Issue 10), MEDLINE via OVID (1946 to November 2014) and EMBASE via OVID (1980 to November 2014). We also searched the U.S. National Institutes of Health Trials Register (https://clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (http://apps.who.int/trialsearch) for ongoing trials. We did not place any restrictions on the language or date of publication when searching the electronic databases.

SELECTION CRITERIA

Randomised controlled trials (RCTs), with an intervention and follow-up period of at least two years, comparing fluoridated milk with non-fluoridated milk.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial risk of bias and extracted data. We used standard methodological procedures expected by The Cochrane Collaboration.

MAIN RESULTS

We included one unpublished RCT, randomising 180 children aged three years at study commencement. The setting was nursery schools in an area with high prevalence of dental caries and a low level of fluoride in drinking water. Data from 166 participants were available for analysis. The study carried a high risk of bias. After three years, there was a reduction of caries in permanent teeth (mean difference (MD) -0.13, 95% confidence interval (CI) -0.24 to -0.02) and in primary teeth (MD -1.14, 95% CI -1.86 to -0.42), as measured by the decayed, missing and filled teeth index (DMFT for permanent teeth and dmft for primary teeth). For primary teeth, this is a substantial reduction, equivalent to a prevented fraction of 31%. For permanent teeth, the disease level was very low in the study, resulting in a small absolute effect size. The included study did not report any other outcomes of interest for this review (adverse events, dental pain, antibiotic use or requirement for general anaesthesia due to dental procedures).

AUTHORS' CONCLUSIONS

There is low quality evidence to suggest fluoridated milk may be beneficial to schoolchildren, contributing to a substantial reduction in dental caries in primary teeth. Due to the low quality of the evidence, further research is likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. There was only one relatively small study, which had important methodological limitations on the data for the effectiveness in reducing caries. Furthermore, there was no information about the potential harms of the intervention. Additional RCTs of high quality are needed before we can draw definitive conclusions about the benefits of milk fluoridation.

Fluoridated milk for preventing dental caries

BACKGROUND

Dental caries remains a major public health problem in most industrialised countries, affecting 60% to 90% of schoolchildren and the vast majority of adults. Milk may provide a relatively cost-effective vehicle for fluoride delivery in the prevention of dental caries. This is an update of a Cochrane review first published in 2005.

OBJECTIVES

To assess the effects of milk fluoridation for preventing dental caries at a community level.

SEARCH METHODS

We searched the Cochrane Oral Health Group Trials Register (inception to November 2014), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2014, Issue 10), MEDLINE via OVID (1946 to November 2014) and EMBASE via OVID (1980 to November 2014). We also searched the U.S. National Institutes of Health Trials Register (https://clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (http://apps.who.int/trialsearch) for ongoing trials. We did not place any restrictions on the language or date of publication when searching the electronic databases.

SELECTION CRITERIA

Randomised controlled trials (RCTs), with an intervention and follow-up period of at least two years, comparing fluoridated milk with non-fluoridated milk.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial risk of bias and extracted data. We used standard methodological procedures expected by The Cochrane Collaboration.

MAIN RESULTS

We included one unpublished RCT, randomising 180 children aged three years at study commencement. The setting was nursery schools in an area with high prevalence of dental caries and a low level of fluoride in drinking water. Data from 166 participants were available for analysis. The study carried a high risk of bias. After three years, there was a reduction of caries in permanent teeth (mean difference (MD) -0.13, 95% confidence interval (CI) -0.24 to -0.02) and in primary teeth (MD -1.14, 95% CI -1.86 to -0.42), as measured by the decayed, missing and filled teeth index (DMFT for permanent teeth and dmft for primary teeth). For primary teeth, this is a substantial reduction, equivalent to a prevented fraction of 31%. For permanent teeth, the disease level was very low in the study, resulting in a small absolute effect size. The included study did not report any other outcomes of interest for this review (adverse events, dental pain, antibiotic use or requirement for general anaesthesia due to dental procedures).

AUTHORS' CONCLUSIONS

There is low quality evidence to suggest fluoridated milk may be beneficial to schoolchildren, contributing to a substantial reduction in dental caries in primary teeth. Due to the low quality of the evidence, further research is likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. There was only one relatively small study, which had important methodological limitations on the data for the effectiveness in reducing caries. Furthermore, there was no information about the potential harms of the intervention. Additional RCTs of high quality are needed before we can draw definitive conclusions about the benefits of milk fluoridation.

Some beneficial effect on root caries from use of higher concentration fluoride toothpaste (5000 ppm F)

DESIGN

Single-blind, multi-centre, parallel, randomised controlled trial. Intervention Adult patients (18-75 years) with 10 or more natural teeth, and one or more root caries lesion in a tooth not crowned or compromised were included. Patients were randomised to receive a high fluoride toothpaste, 1.1% sodium fluoride (5000 ppm F) or a regular toothpaste (1350 ppm F). Packaging was identical and standard brushes were also provided. Patients were strictly instructed to refrain from using toothpastes or toothbrushes other than the ones provided and restricted from using mouth rinses.

OUTCOME MEASURE

The primary outcome measure was changes in the surface structure of the root caries lesions after the intervention. This was graded using a surface hardness score (HS) scale: Level 1: hard; Level 2: hard to leathery; Level 3: leathery; Level 4: leathery with local softening; Level 5: soft. Scores were recorded at baseline, three and six months. Examiners were masked to the group assignment.

RESULTS

One hundred and thirty-five patients (test group: n = 67; control group: n = 68) with 318 identified root caries lesions were randomised. Five patients were lost to follow up, three in the test group and two in the control. The groups were similar at baseline. Overall there was no difference between the two groups for the overall HS (test group: HS = 3.4 ± 0.61; control group: HS = 3.4 ± 0.66; P = 0.8757, unpaired t-test). However the ANOVA revealed significantly better HS for the test group than for the control groups (T1: test group: HS = 2.9 ± 0.67; control group: HS = 3.1 ± 0.75; T2: test group: HS = 2.4 ± 0.81; control group: HS = 2.8 ± 0.79; P < 0.0001).

CONCLUSIONS

The application of a high-fluoride containing dentifrice (5000 ppm F) in adults, twice daily, significantly improves the surface hardness of otherwise untreated root caries lesions when compared with the use of regular fluoride containing (1350 ppm F) toothpastes.

ACKNOWLEDGEMENTS

The authors' institutions received per capita remunerations and the products used in this clinical trial, from Colgate-Palmolive Company. Roger P. Ellwood and Michael Warncke are employees of the Colgate-Palmolive Company.

Interventions for the restorative care of amelogenesis imperfecta in children and adolescents

BACKGROUND

Amelogenesis imperfecta (AI) is a tooth development disorder in which the teeth are covered with thin, abnormally formed enamel. This enamel is easily fractured and damaged, which affects the appearance of the teeth, especially if left untreated. Negative psychological outcomes, due to compromised appearance and function, in patients with AI, have been found to compromise a person's attractiveness and reduce social interaction. The treatment used depends on the severity of the problem.

OBJECTIVES

To compare the success rates of different restorative materials and techniques used for the restoration of anterior and posterior teeth with AI in terms of patient satisfaction (aesthetics and sensitivity) and function.

SEARCH METHODS

We searched the Cochrane Oral Health Group's Trials Register (to 18 April 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 3), MEDLINE via OVID (1946 to 18 April 2013), EMBASE via OVID (1980 to 18 April 2013), CINAHL via EBSCO (1980 to 18 April 2013), Abstracts of the Conference Proceedings of the International Association for Dental Research (2001 to 18 April 2013) and reference lists of relevant articles. There were no restrictions on language or date of publication in the electronic searches.

SELECTION CRITERIA

Randomised controlled trials where children and adolescents with AI who required restoration of teeth were allocated to different restoration techniques would have been selected. Outcomes which would have been evaluated were patient satisfaction, aesthetics, masticatory function and longevity of restorations.

DATA COLLECTION AND ANALYSIS

Two review authors would have extracted data and assessed the risk of bias in included studies independently. Disagreement between the two authors would have been resolved by consulting a third review author. First authors were contacted for additional information and unpublished data.

MAIN RESULTS

No studies met the inclusion criteria for this review.

AUTHORS' CONCLUSIONS

We found no randomised controlled trials of restorative treatments for children and adolescents with AI, and therefore there is no evidence as to which is the best restoration. Well defined randomised controlled trials which recruit children and adolescents and focus on the type and severity of the disorder should be undertaken to determine the best intervention for restoring teeth affected by AI.

Motivational interviewing in an oral health promotion programme

DESIGN

This was a randomised controlled trial (RCT).

INTERVENTION

From a group of patients with mental health problems participants in the motivational interviewing (MI) arm received a brief MI session (15-20 min) conducted by a doctoral psychology student trained in MI, prior to an oral health education session which was focused on exploring advantages and disadvantages, motivation and confidence, and personal values related to daily toothbrushing and oral health. All participants received two pamphlets summarising the information from the education session, instruction in using a mechanical toothbrush, a reminder system, and weekly telephone calls (for 4 weeks).

OUTCOME MEASURE

Plaque scores, oral health knowledge and self-regulation were assessed at baseline and at 4 and 8 weeks.

RESULTS

Sixty participants consented, and 56 (93%) completed the study. Those who did not complete the study discontinued for personal reasons (eg, moving, hospitalisation). Repeated-measures analysis of variance showed improvement (P <0.05) in plaque levels, autonomous regulation and oral health knowledge over time for both groups. Individuals receiving MI improved significantly more, however, compared with people receiving oral health education alone.

CONCLUSIONS

Results suggest that MI is effective at enhancing short-term oral health behaviour change for people with severe mental illness and may be useful for the general population.

A systematic review of the efficacy and safety of fluoridation

SCOPE AND PURPOSE

The systematic review was commissioned by the Australian National Health and Medical Research Council (NHMRC) to evaluate the scientific literature relating to the health effects of fluoride and fluoridation. The systematic review's research questions relate to the caries-reducing benefits and associated potential health risks of providing fluoride systemically (via addition to water, milk and salt) and the use of topical fluoride agents, such as toothpaste, gel, varnish and mouthrinse. Although the review summarises the recent evidence, it does not constitute health policy or clinical practice recommendations.

DATA SOURCES

A literature search was undertaken using the Medline and Embase databases (via www.embase.com). In addition, the Cochrane Systematic Review and Clinical Trial databases were searched to help identify additional systematic reviews and original studies. Because of the availability of recent systematic reviews, searches were limited to publications from 1996 onwards . The search was conducted in December 2006 and limited to English-language publications.

STUDY SELECTION

Based on types of intervention (individual or population) and the outcomes assessed (efficacy or safety), the hierarchy of study types considered most relevant for answering each of the clinical questions defined in this review was chosen (Table 1). The levels of evidence used by NHMRC for intervention and aetiological studies are summarised in Table 2.

DATA EXTRACTION AND SYNTHESIS

Screening of eligible studies was conducted by three reviewers. Data were extracted for all of the included systematic reviews and individual studies using standardised data-extraction forms. This included information about the study design, NHMRC level of evidence, population, intervention, comparator, outcome definitions and results. Information relating to potential biases and study quality were also extracted. Where appropriate, study results were pooled using standard meta-analysis techniques.

RESULTS

In total, 5418 nonduplicate citations were identified. After applying the inclusion and exclusion criteria, 408 citations were considered potentially eligible for inclusion in the review. After the review of the full papers of potentially eligible articles, 77 citations were included in the review. The summary of findings was presented in the context of the research questions (Table 3).

RECOMMENDATIONS

Fluoridation of drinking water remains the most effective and socially equitable means of achieving community-wide exposure to the caries prevention effects of fluoride. It is recommended (see also www.nhmrc.gov.au/news/media/rel07/_files/fluoride_flyer.pdf) that water be fluoridated in the target range of 0.6-1.1 mg/l, depending on the climate, to balance reduction of dental caries and occurrence of dental fluorosis.n particular with reference to care in hospital for those following stroke.

Fluoride prevents caries among adults of all ages

DATA SOURCES

Medline, Embase and the Cochrane Central Register of Controlled Trials were searched. References of each retrieved article were also searched for relevant articles. The US Food and Drug Administration, American Dental Association and manufacturers of topical fluoride products were contacted to identify unpublished trials.

STUDY SELECTION

For inclusion, the study had to be published in the English language, was of duration 1 year or longer, and examined the association between fluoride and caries in intact human teeth in study populations that included adults. To examine the effectiveness of self- or clinically applied fluoride, only longitudinal studies with random assignment of participants or of split-mouth design were included. For studies examining the effectiveness of water fluoridation, cross-sectional studies were included if their participants lived most of their lives in a fluoridated or a nonfluoridated community.

DATA EXTRACTION AND SYNTHESIS

Screening of eligible studies and data extraction were conducted independently and in duplicate. A random-effects model was used to estimate the effect-size of fluoride (absolute difference in annual caries increment or relative risk ratio) for all adults aged 20+ years and for adults aged over 40 years. Root caries increment was also estimated for adults aged over 40 years.

RESULTS

Twenty studies involving 13 551 participants were included in the final body of evidence. Eleven studies examined the effectiveness of self- or clinically applied fluoride. Of these studies, 10 were randomised controlled trials, and one was a controlled trial (split-mouth) that did not specify whether the treatment had been randomly assigned. Nine studies examined the effectiveness of water fluoridation; all were cross-sectioned studies except one which was a prospective cohort trial. Of the studies published after or during 1980, any fluoride (self- and clinically applied or water fluoridation) annually averted 0.29 [95% confidence intervals (CI), 0.16-0.42] carious coronal and 0.22 (95% CI, 0.08-0.37) carious root surfaces. The prevented fraction for water fluoridation was 27.2% (95% CI, 19.4-34.3%).

CONCLUSIONS

These findings suggest that fluoride is effective in preventing caries in adults of all ages.

The prescription and outcomes of fissure sealants applied to a group of high caries risk children by general dental practitioners working in the North West of England

OBJECTIVE

To describe the use and outcomes of fissure sealants applied to the first permanent molars (FPMs) of children with high caries risk.

DESIGN

Retrospective cohort study.

SETTING

General dental practices in North West England.

PARTICIPANTS

677 children between the ages of 5 and 14 years who had dmfs > or =2, and regularly attended 50 general dental practitioners.

OUTCOMES

Analyses were performed at patient level. Logistic regression models, taking into account the clustering of subjects within dental practices, were fitted to identify whether the decision to fissure seal FPMs was significantly associated with gender, socio-economic status, number of carious primary teeth and percentage of carious primary teeth filled. Similar logistic regression models were fitted for caries experience in FPMs.

RESULTS

Poorer children were significantly (p < 0.05, OR = 0.84, 95% CI = 0.71, 0.99) less likely to receive fissure sealants than affluent children, whilst girls (p < 0.01, OR = 1.54, 95% CI = 1.12, 2.12) were more likely to have sealants than boys. The total number of carious primary teeth was also a significant (p < 0.01, OR = 1.15, 95% CI = 1.06, 1.25) independent predictor of dentists' decisions to fissure seal FPMs. For each carious primary tooth, the odds of having caries in FPMs increased by 1.16 (95% CI = 1.06, 1.26). Analysis showed that pit and fissure caries in FPMs was not affected by the presence or absence of fissure sealants.

CONCLUSIONS

The decision to fissure seal FPMs is affected by caries experience in the primary dentition. Girls and affluent children were more likely to receive fissure sealants. It appears that the placement of fissure sealants by general dental practitioners was not effective in preventing pit and fissure caries in these high-risk children.

Fluoridated milk for preventing dental caries

BACKGROUND

Dental caries remains a major public health problem in most industrialised countries, affecting 60% to 90% of school children and the vast majority of adults. Milk provides a relatively cost-effective vehicle for fluoride in the prevention of dental caries.

OBJECTIVES

To determine the effectiveness of fluoridated milk, as a means of delivering fluoride on a community basis, for preventing dental caries.

SEARCH STRATEGY

We searched Cochrane Oral Health Group Trials Register (28 April 2005), Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2005), MEDLINE (1966 to 17 May 2005), OLDMEDLINE (1950 to 1965), EMBASE (1980 to 2005 week 20), LILACS (1982 to 17 May 2005), BBO (1986 to 17 May 2005), SIGLE (1980 to 17 May2005), Digital Dissertations (1861 to 17 May 2005) and reference lists of relevant articles. Attempts were made to identify both unpublished and ongoing studies. There were no language restrictions.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials (RCTs), with an intervention or follow-up period of at least 3 years, comparing fluoridated milk with non-fluoridated milk. Primary outcome was change in caries experience, as measured by changes in decayed, missing and filled figures on tooth (dmft/DMFT) and surface (dmfs/DMFS).

DATA COLLECTION AND ANALYSIS

Inclusion decisions, data extraction and quality assessment were carried out independently and in duplicate. Study authors were contacted for additional information where necessary.

MAIN RESULTS

Two RCTs involving 353 children were included. For permanent teeth, after 3 years there was a significant reduction in the DMFT (78.4%, P < 0.05) between the test and control groups in one trial, but not in the other. The latter study only showed a significant reduction in the DMFT until the fourth (35.5%, P < 0.02) and fifth (31.2%,P < 0.05) years. For primary teeth, again there was a significant reduction in the dmft (31.3%, P< 0.05) between the test and control groups after 3 years in one study, but not in the other. The results could not be pooled because of the difference in concentration of fluoride in the milk.

AUTHORS' CONCLUSIONS

There are insufficient studies with good quality evidence examining the effects of fluoridated milk in preventing dental caries. However, the included studies suggested that fluoridated milk was beneficial to school children, especially their permanent dentition. The data need to be supplemented by further RCTs to provide the highest level of evidence for practice.

Systematic review of ceramic inlays

The purpose of the present study was to conduct a systematic review of ceramic inlays, assess the quality of published clinical studies, and determine the clinical effectiveness of ceramic inlays compared to other forms of posterior restorations. Prospective clinical trials of ceramic inlays published from 1990 to 2001 were retrieved by electronic and hand searching. The methodological quality of each study was assessed by two calibrated reviewers using a standardised checklist. The clinical effectiveness of ceramic inlays was evaluated in terms of failure rate, postoperative pain, and aesthetics. The results were compared to those of other forms of posterior restorations by means of an odds ratio. Among 46 articles selected for quality assessment, only five (10.6%) reported randomised controlled trials and 15 (32.6%) presented controlled clinical trials. The remaining 26 papers (56.5%) were longitudinal clinical trials lacking control groups. Only three papers fulfilled the requirement for statistical analysis to evaluate the clinical effectiveness of ceramic inlays. The results indicate no significant differences in longevity or postoperative sensitivity between ceramic and other posterior restorations over assessment periods of up to 1 year. It is concluded that no strong evidence is available to confirm the clinical effectiveness of ceramic inlays in comparison to other posterior restorations. Greater attention is required to the design and reporting of studies to improve the quality of clinical trials of ceramic inlays.

Pulp treatment for extensive decay in primary teeth

BACKGROUND

Dental decay in primary teeth remains a considerable health problem. Where decay extends to involve the dental pulp, pulp treatment techniques are often used to manage both symptomatic and symptom free teeth.

OBJECTIVES

To assess the relative effectiveness of: various pulp treatment techniques in retaining primary molar teeth with decay involving the pulp for at least 12 months; pulp treatment techniques and extractions in avoiding long term sequelae.

SEARCH STRATEGY

We searched the Cochrane Oral Health Group's Trials Register (August 2002); the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 3, 2002); MEDLINE (January 1966 to August 2002); EMBASE (1980 to August 2002); Science Citation Index Expanded (1981 to August 2002); Social Science Citation Index (1981 to August 2002); Index to Scientific and Technical Proceedings (1982 to August 2002); System for Information on Grey Literature in Europe (August 2002). Key journals were handsearched. There was no restriction on language of publication.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials (RCTs) comparing different pulp treatment techniques (with each other, with extraction or with no treatment) for extensive decay in primary molar teeth. Primary outcomes were extractions following pulp treatment and long term effects.

DATA COLLECTION AND ANALYSIS

Data extraction and quality assessment were carried out independently and in duplicate. Authors were contacted for additional information where necessary.

MAIN RESULTS

Eighty-two studies were identified but only three were suitable for inclusion. Nine studies meeting the inclusion criteria but with inappropriate study design or analysis are also described. Included trials investigated formocresol pulpotomy, ferric sulphate pulpotomy, electrosurgical pulpotomy or zinc oxide eugenol pulpectomy in symptom free, cariously exposed teeth. Data were unavailable on long term effects. Data on extraction following pulp treatment was available in all three studies and in two studies there was no statistically significant difference between the treatments. The difference seen in the other study, where more teeth treated by ferric sulphate pulpotomy were extracted compared to zinc oxide eugenol pulpectomy, must be viewed with caution.

REVIEWER'S CONCLUSIONS

Based on the available RCTs, there is no reliable evidence supporting the superiority of one type of treatment for pulpally involved primary molars. No conclusions can be made as to the optimum treatment or techniques for pulpally involved primary molar teeth due to the scarcity of reliable scientific research. High quality RCTs, with appropriate unit of randomisation and analysis are needed.

Ceramic inlays for restoring posterior teeth

BACKGROUND

In recent decades ceramic inlays have been used with the increasing requirements from patients for tooth-coloured restorations in posterior teeth. Ceramic inlays can offer an excellent appearance, however, their long-term prognosis is uncertain, as only a few studies have reported the long-term clinical performance of these restorations.

OBJECTIVES

To compare the effectiveness of ceramic inlays in posterior teeth with other posterior restorations.

SEARCH STRATEGY

We conducted an electronic search of the Cochrane Oral Health Group Trials Register, the Cochrane Central Register of Controlled Trials ( The Cochrane Library Issue 1, 2002), MEDLINE, and EMBASE from 1990 to 2001. Handsearching included relevant journals and bibliographies of all relevant papers and review articles from 1990 up to 2001. In addition, we contacted experts and companies conducting clinical research on ceramic restorations to find other trials or unpublished materials or to clarify ambiguous or missing data.

SELECTION CRITERIA

Randomized controlled trials, in which the longevity of ceramic inlays is compared with those of other posterior restorations.

DATA COLLECTION AND ANALYSIS

Screening of possible studies and data extraction were independently conducted by two reviewers (MH and AY) using a specially designed chart. Authors of studies were contacted for additional information. The methodological quality of studies was assessed in duplicate using individual components. The Cochrane Oral Health Group statistical guidelines were followed and the results expressed as Odds Ratio (OR) and 95% confidence interval for dichotomous outcomes.

MAIN RESULTS

Two studies fulfilled the criteria to be included in the review. However, one of them was later excluded from the review, as the study design was not clearly described. The remaining, included study, evaluated the clinical performance of 60 ceramic inlays and 20 gold inlays for five years. Seven of the 60 ceramic inlays and two of the 20 gold inlays failed at five-year review. No ceramic inlays resulted in postoperative pain/discomfort after the treatment, however, one gold inlay did. The power of the included study was not great enough to detect an important difference in longevity and postoperative pain/discomfort between ceramic and gold inlays.

REVIEWER'S CONCLUSIONS

There is no strong evidence available to support any differences in the clinical performance of ceramic inlays and other posterior restorations. There is a limited number of well-designed clinical trials within this research area. Greater attention to the design and reporting of studies should be given to improve the study quality of ceramic restoration trials.