PEDro or Cochrane to Assess the Quality of Clinical Trials? A Meta-Epidemiological Study

OBJECTIVE

There is debate on how the methodological quality of clinical trials should be assessed. We compared trials of physical therapy (PT) judged to be of adequate quality based on summary scores from the Physiotherapy Evidence Database (PEDro) scale with trials judged to be of adequate quality by Cochrane Risk of Bias criteria.

DESIGN

Meta-epidemiological study within Cochrane Database of Systematic Reviews.

METHODS

Meta-analyses of PT trials were identified in the Cochrane Database of Systematic Reviews. For each trial PeDro and Cochrane assessments were extracted from the PeDro and Cochrane databases. Adequate quality was defined as adequate generation of random sequence, concealment of allocation, and blinding of outcome assessors (Cochrane criteria) or as trials with a PEDro summary score ≥5 or ≥6 points. We combined trials of adequate quality using random-effects meta-analysis.

RESULTS

Forty-one Cochrane reviews and 353 PT trials were included. All meta-analyses included trials with PEDro scores ≥5, 37 (90.2%) included trials with PEDro scores ≥6 and only 22 (53.7%) meta-analyses included trials of adequate quality according to the Cochrane criteria. Agreement between PeDro and Cochrane was poor for PeDro scores of ≥5 points (kappa = 0.12; 95% CI 0.07 to 0.16) and slight for ≥6 points (kappa 0.24; 95% CI 0.16-0.32). When combining effect sizes of trials deemed to be of adequate quality according to PEDro or Cochrane criteria, we found that a substantial difference in the combined effect size (≥0.15) was evident in 9 (22%) out of the 41 meta-analyses for PEDro cutoff ≥5 and 10 (24%) for cutoff ≥6.

CONCLUSIONS

The PeDro and Cochrane approaches lead to different sets of trials of adequate quality, and different combined treatment estimates from meta-analyses of these trials. A consistent approach to assessing RoB in trials of physical therapy should be adopted.

Poor reliability between Cochrane reviewers and blinded external reviewers when applying the Cochrane risk of bias tool in physical therapy trials

OBJECTIVES

To test the inter-rater reliability of the RoB tool applied to Physical Therapy (PT) trials by comparing ratings from Cochrane review authors with those of blinded external reviewers.

METHODS

Randomized controlled trials (RCTs) in PT were identified by searching the Cochrane Database of Systematic Reviews for meta-analysis of PT interventions. RoB assessments were conducted independently by 2 reviewers blinded to the RoB ratings reported in the Cochrane reviews. Data on RoB assessments from Cochrane reviews and other characteristics of reviews and trials were extracted. Consensus assessments between the two reviewers were then compared with the RoB ratings from the Cochrane reviews. Agreement between Cochrane and blinded external reviewers was assessed using weighted kappa (κ).

RESULTS

In total, 109 trials included in 17 Cochrane reviews were assessed. Inter-rater reliability on the overall RoB assessment between Cochrane review authors and blinded external reviewers was poor (κ  =  0.02, 95%CI: -0.06, 0.06]). Inter-rater reliability on individual domains of the RoB tool was poor (median κ  = 0.19), ranging from κ  =  -0.04 ("Other bias") to κ  =  0.62 ("Sequence generation"). There was also no agreement (κ  =  -0.29, 95%CI: -0.81, 0.35]) in the overall RoB assessment at the meta-analysis level.

CONCLUSIONS

Risk of bias assessments of RCTs using the RoB tool are not consistent across different research groups. Poor agreement was not only demonstrated at the trial level but also at the meta-analysis level. Results have implications for decision making since different recommendations can be reached depending on the group analyzing the evidence. Improved guidelines to consistently apply the RoB tool and revisions to the tool for different health areas are needed.

Impact of Sense of Coherence on Oral Health Behaviors: A Systematic Review

Objectives

The aim of this review was to critically analyze the empirical evidence on the association between Sense of Coherence (SOC) and oral health behaviors through a systematic approach.

Methods

A systematic search up to April 2015 was carried out using the following electronic bibliographic databases: PubMed, Ovid MEDLINE; ISI Web of Science; and Ovid PsychInfo. Studies were included if they evaluated the relationship between SOC and oral health behaviors including tooth cleaning, fluoride usage, dietary habits, dental attendance, and smoking. We excluded studies that only assessed the relationship between oral health status and SOC without evaluating oral health behaviors. The New Castle Ottawa (NOS) quality assessment checklist was employed to evaluate the methodological quality of included studies.

Results

Thirty-nine potential papers met the preliminary selection criteria and following a full-text review, 9 papers were finally selected for this systematic review. Results provided by the included studies indicated different levels of association between SOC and oral health behaviors. The most frequent behaviors investigated were tooth brushing and dental attendance pattern. The impact of SOC on performing positive oral health behaviors, to some extent, was related to demographic and socio-economic factors. In addition, mothers’ SOC influenced children’s oral health practices.

Conclusions

A more favorable oral health behavior was observed among those with a stronger SOC suggesting that the SOC can be a determinant of oral health-related behaviors including tooth brushing frequency, daily smoking, and dental attendance.

Influence of blinding on treatment effect size estimate in randomized controlled trials of oral health interventions

Background

Recent methodologic evidence suggests that lack of blinding in randomized trials can result in under- or overestimation of the treatment effect size. The objective of this study is to quantify the extent of bias associated with blinding in randomized controlled trials of oral health interventions.

Methods

We selected all oral health meta-analyses that included a minimum of five randomized controlled trials. We extracted data, in duplicate, related to nine blinding-related criteria, namely: patient blinding, assessor blinding, care-provider blinding, investigator blinding, statistician blinding, blinding of both patients and assessors, study described as “double blind”, blinding of patients, assessors, and care providers concurrently, and the appropriateness of blinding. We quantified the impact of bias associated with blinding on the magnitude of effect size using a two-level meta-meta-analytic approach with a random effects model to allow for intra- and inter-meta-analysis heterogeneity.

Results

We identified 540 randomized controlled trials, included in 64 meta-analyses, analyzing data from 137,957 patients. We identified significantly larger treatment effect size estimates in trials that had inadequate patient blinding (difference in treatment effect size = 0.12; 95% CI: 0.00 to 0.23), lack of blinding of both patients and assessors (difference = 0.19; 95% CI: 0.06 to 0.32), and lack of blinding of patients, assessors, and care-providers concurrently (difference = 0.14; 95% CI: 0.03 to 0.25). In contrast, assessor blinding (difference = 0.06; 95% CI: -0.06 to 0.18), caregiver blinding (difference = 0.02; 95% CI: -0.04 to 0.09), principal-investigator blinding (difference = − 0.02; 95% CI: -0.10 to 0.06), describing a trial as “double-blind” (difference = 0.09; 95% CI: -0.05 to 0.22), and lack of an appropriate method of blinding (difference = 0.06; 95% CI: -0.06 to 0.18) were not associated with over- or underestimated treatment effect size.

Conclusions

We found significant differences in treatment effect size estimates between oral health trials based on lack of patient and assessor blinding. Treatment effect size estimates were 0.19 and 0.14 larger in trials with lack of blinding of both patients and assessors and blinding of patients, assessors, and care-providers concurrently. No significant differences were identified in other blinding criteria. Investigators of oral health systematic reviews should perform sensitivity analyses based on the adequacy of blinding in included trials.

Electronic supplementary material

The online version of this article (10.1186/s12874-018-0491-0) contains supplementary material, which is available to authorized users.

What is the influence of randomisation sequence generation and allocation concealment on treatment effects of physical therapy trials? A meta-epidemiological study

OBJECTIVE

To determine if adequacy of randomisation and allocation concealment is associated with changes in effect sizes (ES) when comparing physical therapy (PT) trials with and without these methodological characteristics.

DESIGN

Meta-epidemiological study.

PARTICIPANTS

A random sample of randomised controlled trials (RCTs) included in meta-analyses in the PT discipline were identified.

INTERVENTION

Data extraction including assessments of random sequence generation and allocation concealment was conducted independently by two reviewers. To determine the association between sequence generation, and allocation concealment and ES, a two-level analysis was conducted using a meta-meta-analytic approach.

PRIMARY AND SECONDARY OUTCOME MEASURES

association between random sequence generation and allocation concealment and ES in PT trials.

RESULTS

393 trials included in 43 meta-analyses, analysing 44,622 patients contributed to this study. Adequate random sequence generation and appropriate allocation concealment were accomplished in only 39.7% and 11.5% of PT trials, respectively. Although trials with inappropriate allocation concealment tended to have an overestimate treatment effect when compared with trials with adequate concealment of allocation, the difference was non-statistically significant (ES=0.12; 95% CI -0.06 to 0.30). When pooling our results with those of Nuesch et al, we obtained a pooled statistically significant value (ES=0.14; 95% CI 0.02 to 0.26). There was no difference in ES in trials with appropriate or inappropriate random sequence generation (ES=0.02; 95% CI -0.12 to 0.15).

CONCLUSIONS

Our results suggest that when evaluating risk of bias of primary RCTs in PT area, systematic reviewers and clinicians implementing research into practice should pay attention to these biases since they could exaggerate treatment effects. Systematic reviewers should perform sensitivity analysis including trials with low risk of bias in these domains as primary analysis and/or in combination with less restrictive analyses. Authors and editors should make sure that allocation concealment and random sequence generation are properly reported in trial reports.

Radiologically determined orthodontically induced external apical root resorption in incisors after non-surgical orthodontic treatment of class II division 1 malocclusion: a systematic review

This study aims to critically evaluate orthodontically induced external apical root resorption (OIEARR) in incisors of patients undergoing non-surgical orthodontic treatment of class II division 1 malocclusion by a systematic review of the published data. An electronic search of two databases was performed; the bibliographies of relevant articles were also reviewed. Studies were included if they examined the amount of OIEARR in incisors produced during non-surgical orthodontic treatment of individuals with class II division I malocclusion in the permanent dentition. Individuals had no previous history of OIEARR, syndromes, pathologies, or general diseases. Study selections, risk of bias assessment, and data extraction were performed in duplicate. Eight studies of moderate methodological quality were finally included. An increased prevalence (65.6% to 98.1%) and mild to moderate severity of OIEARR (<4 mm and <1/3 original root) were reported. No sex difference in root resorption was found. For the maxillary incisors, there was no evidence that either the central or lateral incisor was more susceptible to OIEARR. A weak to moderate positive correlation between treatment duration and root resorption, and anteroposterior apical displacement and root resorption was found. Current limited evidence suggests that non-surgical comprehensive orthodontic treatment to correct class II division 1 malocclusions causes increased prevalence and severity of OIEARR the more the incisor roots are displaced and the longer this movement takes.

Indices to assess malocclusions in patients with cleft lip and palate

BACKGROUND

Several indices are now available to assess the severity of the malocclusion in cleft lip and/or palate (CLP) patients; and although it has been quite some time since the introduction of these indices, there is no consensus as to which index should be used for CLP populations.

OBJECTIVE

To systematically review the available literature on the indices used to assess the occlusal schemes in dental models of CLP patients, with respect to the most commonly used index and the index that most fulfils the World Health Organization (WHO) criteria.

SEARCH METHODS

Ten electronic databases, grey literature, and reference list searches were conducted.

SELECTION CRITERIA

The inclusion criteria consisted of studies that aimed to assess a particular malocclusion index on study models of patients with CLP.

DATA COLLECTION AND ANALYSIS

Full articles were retrieved from abstracts/titles that appeared to have met the inclusion -exclusion criteria which were subsequently reviewed using more detailed criteria for a final selection decision. The Quality Assessment of Diagnostic Accuracy Studies tool was used to appraise the methodological quality of the finally included studies. Due to the heterogeneity of the data, only a qualitative analysis was performed.

RESULTS

A total of 13 studies met the inclusion -exclusion criteria. These studies revealed seven utilized indices, namely the GOSLON Yardstick, Five-Year-Old, Bauru-Bilateral Cleft Lip and Palate Yardstick, Huddart -Bodenham, Modified Huddart -Bodenham, EUROCRAN Yardstick, and GOAL Yardstick. The GOSLON Yardstick was the most commonly used index, and the Modified Huddart -Bodenham performed the best according to the WHO criteria.

CONCLUSIONS

Current evidence suggests that the Modified Huddart -Bodenham Index equalled or outperformed the rest of the indices on all the WHO criteria and that the GOSLON Yardstick was the most commonly used index, possibly due to a longer time in use. Therefore, the Modified Huddart -Bodenham could be considered as the standard to measure outcomes of patients with CLP.

Long-term skeletal stability after maxillary advancement with distraction osteogenesis in cleft lip and palate patients

OBJECTIVE

To systematically review the long-term skeletal stability after maxillary advancement with distraction osteogenesis (DO) in cleft lip and palate (CLP) patients.

MATERIALS AND METHODS

Electronic databases, grey literature, and reference list searches were conducted. The inclusion criteria were stability of maxillary advancement with distraction osteogenesis assessed at the posttreatment follow-up ≥ 1 year in CLP patients. Full articles were retrieved from abstracts or titles that appear to meet the inclusion criteria or lacked sufficient detail for immediate exclusion. Once full articles were collected, they were again reviewed considering more detailed inclusion criteria for a final selection decision. A methodologic quality assessment tool was utilized.

RESULTS

Thirty abstracts/titles met the initial search criteria, and 13 articles were finally selected. Overall, methodologic quality scores were high in only one randomized clinical trial. After maxillary advancement with DO in CLP patients, the long-term horizontal relapse in A-point was less than 15% in eight studies and between 20% and 25% in four studies. The study that was judged as a high-quality study reported 8.2% horizontal relapse in A-point. The relapse rate was higher in DO with external distracter device than DO with internal distracter device.

CONCLUSIONS

Current evidence suggests maxillary advancement with DO has good stability in CLP patients with moderate and severe maxillary hypoplasia.

Inconsistency in the items included in tools used in general health research and physical therapy to evaluate the methodological quality of randomized controlled trials: a descriptive analysis

Background

Assessing the risk of bias of randomized controlled trials (RCTs) is crucial to understand how biases affect treatment effect estimates. A number of tools have been developed to evaluate risk of bias of RCTs; however, it is unknown how these tools compare to each other in the items included. The main objective of this study was to describe which individual items are included in RCT quality tools used in general health and physical therapy (PT) research, and how these items compare to those of the Cochrane Risk of Bias (RoB) tool.

Methods

We used comprehensive literature searches and a systematic approach to identify tools that evaluated the methodological quality or risk of bias of RCTs in general health and PT research. We extracted individual items from all quality tools. We calculated the frequency of quality items used across tools and compared them to those in the RoB tool. Comparisons were made between general health and PT quality tools using Chi-squared tests.

Results

In addition to the RoB tool, 26 quality tools were identified, with 19 being used in general health and seven in PT research. The total number of quality items included in general health research tools was 130, compared with 48 items across PT tools and seven items in the RoB tool. The most frequently included items in general health research tools (14/19, 74%) were inclusion and exclusion criteria, and appropriate statistical analysis. In contrast, the most frequent items included in PT tools (86%, 6/7) were: baseline comparability, blinding of investigator/assessor, and use of intention-to-treat analysis. Key items of the RoB tool (sequence generation and allocation concealment) were included in 71% (5/7) of PT tools, and 63% (12/19) and 37% (7/19) of general health research tools, respectively.

Conclusions

There is extensive item variation across tools that evaluate the risk of bias of RCTs in health research. Results call for an in-depth analysis of items that should be used to assess risk of bias of RCTs. Further empirical evidence on the use of individual items and the psychometric properties of risk of bias tools is needed.

MRI and CBCT image registration of temporomandibular joint: a systematic review

Purpose

The purpose of the present review is to systematically and critically analyze the available literature regarding the importance, applicability, and practicality of (MRI), computerized tomography (CT) or cone-beam CT (CBCT) image registration for TMJ anatomy and assessment.

Data sources

A systematic search of 4 databases; MEDLINE, EMBASE, EBM reviews and Scopus, was conducted by 2 reviewers. An additional manual search of the bibliography was performed.

Inclusion criteria

All articles discussing the magnetic resonance imaging MRI and CT or CBCT image registration for temporomandibular joint (TMJ) visualization or assessment were included.

Results and included articles’ characteristics

Only 3 articles satisfied the inclusion criteria. All included articles were published within the last 7 years. Two articles described MRI to CT multimodality image registration as a complementary tool to visualize TMJ. Both articles used images of one patient only to introduce the complementary concept of MRI-CT fused image. One article assessed the reliability of using MRI-CBCT registration to evaluate the TMJ disc position and osseous pathology for 10 temporomandibular disorder (TMD) patients.

Conclusion

There are very limited studies of MRI-CT/CBCT registration to reach a conclusion regarding its accuracy or clinical use in the temporomandibular joints.

Electronic supplementary material

The online version of this article (doi:10.1186/s40463-016-0144-4) contains supplementary material, which is available to authorized users.

Impact of acculturation on oral health among immigrants and ethnic minorities: A systematic review

OBJECTIVE

Cultural changes faced by immigrants and ethnic minorities after moving to a host country may have a detrimental or beneficial influence on their oral health and oral health-related behaviors. Therefore, this paper reviews the literature to see the impact of acculturation on immigrants and ethnic minorities' oral health outcomes.

METHODS

We searched seven electronic databases up to January 2018. All cross-sectional and longitudinal quantitative studies that examined associations between acculturation and oral health status and/or oral health behaviors among ethnic minority and immigrant population[s] were included. Study selection, data extraction, and risk of bias assessment were completed in duplicate. The Newcastle-Ottawa checklist was used to appraise the methodological quality of the quantitative studies. A meta-analytic approach was not feasible.

RESULTS

A total of 42 quantitative studies were identified. The studies showed a positive association between acculturation and oral health status/behaviors. The most frequently used acculturation indicators were language spoken by immigrant and ethnic minorities and length of stay at the host country. High-acculturated immigrant and ethnic minority groups demonstrated better oral health outcomes, oral health behaviors, dental care utilization, and dental knowledge.

CONCLUSIONS

According to existing evidence, a positive effect of acculturation on oral health status and behaviors was found.

PRACTICAL IMPLICATIONS

Dental practitioners should be culturally competent to provide the appropriate services and treatments to immigrant and ethnic minorities. Policymakers should also be sensitive to cultural diversities and properly address the unique needs of each group in order to maintain oral health equity.

Effect of molar intrusion with temporary anchorage devices in patients with anterior open bite: a systematic review

OBJECTIVE

The objective of the study is to assess the effect of molar intrusion with temporary anchorage devices on the vertical facial morphology and mandibular rotation during open bite treatment in the permanent dentition.

METHODS

We performed a systematic review of the published data in seven electronic databases up to September 2015. We considered studies for inclusion if they were examining the effects of posterior teeth intrusion on the vertical facial morphology with open bite malocclusion in the permanent dentition. Study selection, risk of bias assessment, and data-extraction were performed in duplicate. Meta-analysis was not possible due to dissimilarity and heterogeneity among the included studies.

RESULTS

Out of the 42 articles that met the initial eligibility criteria, 12 studies were finally selected. Low level of scientific evidence was identified after risk of bias assessment of the included studies with no relevant randomized controlled trial performed. Out of the 12 selected studies, five studies used miniplates and seven studies used miniscrews. Mandibular counterclockwise rotation was found to be between 2.3° and 3.9° in six studies (as sassed by mandibular plane angle, between MeGo or GoGn and SN or FH plane) while it was less than 2° in the remaining studies.

CONCLUSIONS

Current weak evidence suggests that molar intrusion with temporary anchorage devices may cause mandibular counterclockwise autorotation. Future well-conducted and clearly reported multicenter randomized controlled trials that include a non-treatment control group are needed to make robust recommendations regarding the amount of mandibular rotation during open bite treatments.

Impact of social support on oral health among immigrants and ethnic minorities: A systematic review

Objective

Adaptation to social life changes after migration may be beneficial or detrimental to migrants’ oral health outcomes and related behaviors. This systematic review aims to synthesize the scientific literature on the impact of social support on immigrants’ and ethnic minorities’ oral health status and/or behaviors.

Methods

A comprehensive electronic search, up to November 2018, was conducted using five electronic databases. We included cross-sectional and longitudinal quantitative studies that examine associations between social support and oral health outcomes among immigrants and ethnic minorities. Study selection, data extraction, and risk of bias assessment were completed in duplicate and the Newcastle-Ottawa checklist was used to appraise the methodological quality of the quantitative studies.

Results

A total of 26 studies met the eligibility criteria. Included studies examined multiple oral health outcomes such as dental care utilization, oral health behaviors, oral health problems, self-rated oral health, oral health knowledge, and oral health-related quality of life among immigrants and ethnic minorities. The social support level is assessed either by social support indicators or by adapting certain scales. Overall, social support was found to be positively associated with dental care utilization, number of carious teeth, periodontal disease, oral health behaviors, oral health knowledge, oral health-related quality of life, and self-rated oral health.

Conclusion

Although immigrants and ethnic minorities encounter several challenges after migration to a new country that could affect their oral health, social support from their surrounding environment in the form of structural or functional support plays an important role in improving their oral health outcomes.

Patient experiences with the Forsus Fatigue Resistant Device

OBJECTIVE

To investigate patients' experiences with the Forsus Fatigue Resistant Device (FFRD).

METHODS

This was a survey focused on patient's comprehensive experience with FFRD, both initially and after several months of wear, including the patient's overall impression of the appliance. The survey was administered to 70 patients wearing FFRD in both university and private practice settings.

RESULTS

A high percentage (81.5%) reported a neutral to favorable experience with FFRD; 89.8% reported growing accustomed to the appliance within 4 weeks. The majority of those who had previously worn rubber bands found FFRD to be "easier." Cheek irritation was the most serious side effect (about 50%). Cheek irritation and other negative effects generally decreased over time.

CONCLUSIONS

The FFRD is relatively well accepted by patients. Most patients experience some discomfort and functional limitations; however, the effect generally diminishes with time, and patients adapt to the appliance. Practitioners should be especially vigilant about problems with cheek irritation.

Randomized clinical trials in dentistry: Risks of bias, risks of random errors, reporting quality, and methodologic quality over the years 1955-2013

OBJECTIVES

To examine the risks of bias, risks of random errors, reporting quality, and methodological quality of randomized clinical trials of oral health interventions and the development of these aspects over time.

METHODS

We included 540 randomized clinical trials from 64 selected systematic reviews. We extracted, in duplicate, details from each of the selected randomized clinical trials with respect to publication and trial characteristics, reporting and methodologic characteristics, and Cochrane risk of bias domains. We analyzed data using logistic regression and Chi-square statistics.

RESULTS

Sequence generation was assessed to be inadequate (at unclear or high risk of bias) in 68% (n = 367) of the trials, while allocation concealment was inadequate in the majority of trials (n = 464; 85.9%). Blinding of participants and blinding of the outcome assessment were judged to be inadequate in 28.5% (n = 154) and 40.5% (n = 219) of the trials, respectively. A sample size calculation before the initiation of the study was not performed/reported in 79.1% (n = 427) of the trials, while the sample size was assessed as adequate in only 17.6% (n = 95) of the trials. Two thirds of the trials were not described as double blinded (n = 358; 66.3%), while the method of blinding was appropriate in 53% (n = 286) of the trials. We identified a significant decrease over time (1955-2013) in the proportion of trials assessed as having inadequately addressed methodological quality items (P < 0.05) in 30 out of the 40 quality criteria, or as being inadequate (at high or unclear risk of bias) in five domains of the Cochrane risk of bias tool: sequence generation, allocation concealment, incomplete outcome data, other sources of bias, and overall risk of bias.

CONCLUSIONS

The risks of bias, risks of random errors, reporting quality, and methodological quality of randomized clinical trials of oral health interventions have improved over time; however, further efforts that contribute to the development of more stringent methodology and detailed reporting of trials are still needed.

A descriptive analysis of oral health systematic reviews published 1991-2012: cross sectional study

Objectives

To identify all systematic reviews (SRs) published in the domain of oral health research and describe them in terms of their epidemiological and descriptive characteristics.

Design

Cross sectional, descriptive study.

Methods

An electronic search of seven databases was performed from inception through May 2012; bibliographies of relevant publications were also reviewed. Studies were considered for inclusion if they were oral health SRs defined as therapeutic or non-therapeutic investigations that studied a topic or an intervention related to dental, oral or craniofacial diseases/disorders. Data were extracted from all the SRs based on a number of epidemiological and descriptive characteristics. Data were analysed descriptively for all the SRs, within each of the nine dental specialities, and for Cochrane and non-Cochrane SRs separately.

Results

1,188 oral health (126 Cochrane and 1062 non-Cochrane) SRs published from 1991 through May 2012 were identified, encompassing the nine dental specialties. Over half (n = 676; 56.9%) of the SRs were published in specialty oral health journals, with almost all (n = 1,178; 99.2%) of the SRs published in English and almost none of the non-Cochrane SRs (n = 11; 0.9%) consisting of updates of previously published SRs. 75.3% of the SRs were categorized as therapeutic, with 64.5% examining non-drug interventions, while approximately half (n = 150/294; 51%) of the non-therapeutic SRs were classified as epidemiological SRs. The SRs included a median of 15 studies, with a meta-analysis conducted in 43.6%, in which a median of 9 studies/1 randomized trial were included in the largest meta-analysis conducted. Funding was received for 25.1% of the SRs, including nearly three-quarters (n = 96; 76.2%) of the Cochrane SRs.

Conclusion

Epidemiological and descriptive characteristics of the 1,188 oral health SRs varied across the nine dental specialties and by SR category (Cochrane vs. non-Cochrane). There is a clear need for more updates of SRs in all the dental specialties.

Effectiveness of the transpalatal arch in controlling orthodontic anchorage in maxillary premolar extraction cases: A systematic review and meta-analysis

OBJECTIVE

To evaluate the effectiveness of the transpalatal arch (TPA) as an anchorage device in preventing maxillary molar mesialization during retraction of the anterior teeth after premolar extraction.

MATERIALS AND METHODS

This systematic review intended to include patients indicated for upper premolar bilateral extraction and subsequent retraction of anterior teeth, considering the use of TPA as an anchorage tool in one of the treatment groups. The search was systematically performed, up to April 2015, in the following electronic databases: Medline, Embase, and all evidence-based medicine reviews via OVID, Cochrane Library, Scopus, PubMed, and Web of Science. Risk of bias assessment was performed using Cochrane's Risk of Bias Tool for randomized clinical trials (RCTs) and Methodological Index for Nonrandomized Studies (MINORS) for non-RCTs.

RESULTS

Fourteen articles were finally included. Nine RCTs and five non-RCTs presented moderate to high risk of bias. Only one study investigated the use of TPA in comparison with no anchorage, failing to show significant differences regarding molar anchorage loss. A meta-analysis showed a significant increase in anchorage control when temporary anchorage devices were compared with TPA (mean difference [MD] 2.09 [95% confidence interval {CI} 1.80 to 2.38], seven trials), TPA + headgear (MD 1.71 [95% CI 0.81 to 2.6], four trials), and TPA + utility arch (MD 0.63 [95% CI 0.12 to 1.15], 3 trials).

CONCLUSION

Based on mostly moderate risk of bias and with some certainty level, TPA alone should not be recommended to provide maximum anchorage during retraction of anterior teeth in extraction cases.

Association between sleep apnea and low bone mass in adults: a systematic review and meta-analysis

We performed a systematic review of the literature to assess the association between sleep apnea and bone metabolism diseases including osteoporosis in adult population. Results from clinical trials suggest that the association between sleep apnea and low bone mass in adults is possible.

INTRODUCTION

This study aimed to synthesize existing evidence on the potential association between sleep apnea and low bone mass in adults.

METHODS

Electronic searches of five databases were performed. The inclusion criteria consisted of studies in humans that assessed potential associations between sleep apnea and bone metabolic diseases in an adult population. For diagnosis of sleep apnea overnight polysomnography, home polygraphy, or validated records from healthcare databases were considered. Reduced bone density, osteoporosis, serum/urinary levels for markers of bone formation and resorption, or risk of fractures caused without history of trauma were considered indicators of low bone mass. A random-effects model meta-analysis was applied when possible.

RESULTS

Of the 963 relevant references, 12 studies met our inclusion criteria and were assessed to be of medium to low bias. Nine out of 12 studies reported an association between sleep apnea and low bone mass (increased bone resorption markers, reduced bone density, and higher risk of osteoporosis). Two studies did not report a significant association, whereas one study reported an increase of bone density in sleep apnea patients compared to non-sleep apnea patients. Meta-analysis of 2 studies (n = 112,258 patients) showed that sleep apnea was a significant risk factor for osteoporosis (odds ratio (OR), 1.92; 95%CI, 1.24 to 2.97; I² = 66%); females only had an OR of 2.56 (95% CI, 1.96 to 3.34; I² = 0%) while the OR in males was 2.03 (95% CI, 1.24 to 3.35; I² = 38%).

CONCLUSIONS

An association between sleep apnea and low bone mass in adults is plausible, but supporting evidence has a risk of bias and is inconsistent.

Effect of Low-Intensity Pulsed Ultrasound on Distraction Osteogenesis Treatment Time: A Meta-analysis of Randomized Clinical Trials

OBJECTIVES

The objectives of this systematic review with a meta-analysis were to critically analyze the available scientific literature regarding the effects of low-intensity pulsed ultrasound (US) on stimulating bone regeneration and bone maturation during distraction osteogenesis in humans and to determine whether the stimulatory effect of low-intensity pulsed US can effectively reduce the associated treatment time.

METHODS

Studies were considered for inclusion if they were randomized clinical trials that examined the effect of low-intensity pulsed US on distraction osteogenesis compared to conventional distraction osteogenesis. The primary outcome was reduced treatment time. Study selection, risk of bias assessment, and data extraction were performed in duplicate. A random-effects meta-analysis model was used when more than 3 trials were eligible for a quantitative analysis and considering the expected differences in interventions and measurement tools.

RESULTS

Five randomized clinical trials, with a moderate to high risk of bias, met the eligibility criteria. Four trials examining tibial distraction osteogenesis in 118 patients were combined in a meta-analysis. A statistically significant difference for reduced treatment time between distraction osteogenesis with low-intensity pulsed US and standard distraction osteogenesis was evident (mean difference, -15.236 d/cm; random-effects 95% confidence interval, -19.902 to -10.569 d/cm; P < .0001). As for the mandible, only 1 clinical trial was available, which showed no significant effect of low-intensity pulsed US therapy on distraction osteogenesis.

CONCLUSIONS

Current available evidence suggests that low-intensity pulsed US therapy may provide a reduction in the overall treatment time for tibial distraction osteogenesis. However, this conclusion should be considered with caution, given the moderate to high risk of bias in the included randomized clinical trials.

How should we evaluate the risk of bias of physical therapy trials?: a psychometric and meta-epidemiological approach towards developing guidelines for the design, conduct, and reporting of RCTs in Physical Therapy (PT) area: a study protocol

BACKGROUND

Numerous tools and items have been developed in all health areas to assess the risk of bias of randomized controlled trials (RCTs). The Cochrane Collaboration (CC) released a new tool to assess bias in RCTs, based on empirical evidence quantifying the association between some design features and estimates of treatment effects (TEs). However, this evidence is limited to medicine and investigating a selected set of components. No such studies have been conducted in other health areas such as Physical Therapy (PT) and allied health professions. Evidence specific to the PT area is needed to understand and quantify the association between design features and TE estimates to inform practice and decision-making in this field. The overall goal of this project is to provide direction for the design, conduct, reporting and bias assessment of PT RCTs. We will achieve this through the following specific objectives and methods.

METHODS/DESIGN

1) to measure the association between methodological components and other factors (for example, PT area, type of intervention, type of outcomes) and TE estimates in RCTs in PT, 40 randomly selected meta-analyses of RCTs involving PT interventions will be identified from the Cochrane Database of Systematic Reviews. Trials will be evaluated independently by two reviewers using the most commonly used tools in the PT field. A two-level analysis will be conducted using a meta-meta-analytic approach; 2) to identify relevant items to evaluate risk of bias of PT trials, an exploratory factor analysis (EFA) will be used to identify the latent structure of the items; 3) to develop guidelines for the design, conduct, reporting, and risk of bias assessment of PT RCTs, items obtained from the factor analysis and the meta-epidemiological approach will be further evaluated by experts in PT through a web-based survey following a Delphi procedure.

DISCUSSION

The results of this project will have a direct impact on research and practice in PT and are valuable to a number of stakeholders: researchers when designing, conducting, and reporting trials; systematic reviewers and meta-analysts when synthesizing trial results; physiotherapists when making day-to-day treatment decision; and, other healthcare decision-makers, such as those developing policy or practice guidelines.

Evaluation of risk of bias assessment of trials in systematic reviews of oral health interventions, 1991-2014: A methodology study

BACKGROUND

The authors aimed to describe how often and by what means investigators assessed the risk of bias of clinical trials in systematic reviews of oral health interventions and to identify factors associated with risk of bias assessments.

METHODS

The authors selected therapeutic oral health systematic reviews published from 1991 through 2014. They extracted data related to the tools used for risk of bias assessment of primary studies and data related to other review characteristics. They descriptively analyzed the data and used multivariate logistic regression.

RESULTS

The authors identified 1,114 oral health systematic reviews (130 Cochrane reviews and 984 non-Cochrane reviews). The investigators of the primary studies assessed risk of bias in 61.4% of the reviews, and the risk of bias assessments occurred more often in Cochrane reviews than in non-Cochrane reviews (100% versus 56.3%; P < .001) and in reviews published after the dissemination of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement (odds ratio [OR], 1.55; 95% confidence interval [CI], 1.17-2.06). Compared with the investigators of reviews of public oral health interventions, investigators of reviews of oral surgery were less likely to assess risk of bias (OR, 0.41; 95% CI, 0.25-0.67). Furthermore, the investigators of systematic reviews published in dental journals were less likely to assess risk of bias of individual trials (OR, 0.28; 95% CI, 0.19-0.41) compared with the investigators of reviews published in nondental journals.

CONCLUSIONS

The investigators of primary studies did not undertake risk of bias assessment in a considerable portion of non-Cochrane oral health systematic reviews. The investigators of reviews published in dental journals were less likely to assess risk of bias than the investigators of reviews published in nondental journals. The results of this study provide evidence of the need for improving the conduct and reporting of oral health systematic reviews with respect to risk of bias assessment.

PRACTICAL IMPLICATIONS

Clinicians should determine to what extent the findings of a systematic review are valid on the basis of whether the investigators assessed and considered risk of bias during the interpretation of findings.

The relationship between vertical facial morphology and overjet in untreated Class II subjects

OBJECTIVE

To evaluate the association between vertical facial morphology and overjet in untreated Class II subjects.

MATERIALS AND METHODS

The lateral cephalograms of 140 untreated Class II subjects (68 males and 72 females) between 8 and 11 years of age were divided into three groups based on their overjet value as measured on study casts: Group I normal overjet (less than 3 mm), Group II increased overjet (more than 3 mm but less than or equal to 6 mm), and Group III extreme overjet (more than 6 mm). Mean values and standard deviations of 28 variables measured on lateral cephalograms were calculated. Differences between the three groups were tested using one-way analysis of variance (ANOVA), followed by Bonferroni tests. Additionally, cephalometric differences between groups and available normal values for the Syrian population were evaluated using an independent t-test.

RESULTS

Subjects with normal overjet showed a horizontal facial pattern and posterior inclination of the maxilla, whereas increased overjet subjects exhibited a neutral facial pattern. In contrast, subjects with extreme overjet had a vertical facial pattern and anterior inclination of the maxilla. The mandible was retrognathic and the maxilla was normally positioned in the three groups.

CONCLUSIONS

A positive association was found between the overjet and the tendency toward a hyperdivergent pattern.