Variations in odontological care routines for patients undergoing treatment for head and neck cancer in county councils/regions of Sweden

OBJECTIVE

To investigate current odontological care routines for patients treated for head and neck cancers in the county councils/regions (C/Rs) of Sweden.

METHODS

An invitation to fill in a web-based questionnaire was sent to dentists/dental hygienists working in dental clinics in the 12 C/Rs, treating and responsible for the odontological care of patients undergoing treatment for cancer of the head and neck. The questionnaire started with two mandatory and one non-mandatory questions, followed by questions regarding routines before (n = 28), during (n = 23), and after (n = 9) treatment, plus two additional questions, totalling 65 questions.

RESULTS

Four dental hygienists and six dentists in 10 of the 12 C/Rs answered the questionnaire. Three C/Rs stated that they measure both the unstimulated and stimulated salivary secretion rate, and another C/R stated that they measure the stimulated secretion rate only. Similar recommendations were given regarding oral hygiene, salivary stimulants and substitutes, and extra fluoride. However, great variations were seen regarding recommendations for preventing and relieving oral mucositis. There were also discrepancies regarding information about the importance of avoiding smoking and alcohol. In seven C/Rs, patients visited the dental hygienist once a week during cancer treatment.

CONCLUSION

The results suggests that there are great variations in odontological care given to patients undergoing treatment for cancer of the head and neck region in different county councils/regions in Sweden. There is a need to develop and implement evidence-based guidelines to decrease the risk of oral complications and increase both the quality of life and the quality of care.

A practical approach to evidence-based dentistry: IV: how to use an article about harm

BACKGROUND AND OVERVIEW

Questions regarding harm are common in dental practice. Observational, nonrandomized studies (that is, cohort studies and case-control studies) are the designs used by investigators to answer most of these questions. A critical appraisal of these studies should include an assessment of the risk of bias, the results, and the applicability of the study. The authors provide the concepts and guidelines that dentists can apply to most effectively use articles regarding harm to guide their clinical practice.

PRACTICAL IMPLICATIONS

Dentists who wish to inform their clinical decisions regarding questions of harm can use these guidelines to decide what type of studies to search, define the specific question of interest to search efficiently for these studies, and critically appraise an article about harm.

Evidence-based Clinical Practice Guideline for the Use of Pit-and-Fissure Sealants

BACKGROUND

This article presents evidence-based clinical recommendations for the use of pit-and-fissure sealants on the occlusal surfaces of primary and permanent molars in children and adolescents. A guideline panel convened by the American Dental Association (ADA) Council on Scientific Affairs and the American Academy of Pediatric Dentistry conducted a systematic review and formulated recommendations to address clinical questions in relation to the efficacy, retention, and potential side effects of sealants to prevent dental caries; their efficacy compared with fluoride varnishes; and a head-to-head comparison of the different types of sealant material used to prevent caries on pits-and-fissures of occlusal surfaces.

TYPES OF STUDIES REVIEWED

This is an update of the ADA 2008 recommendations on the use of pit-and-fissure sealants on the occlusal surfaces of primary and permanent molars. The authors conducted a systematic search in MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and other sources to identify randomized controlled trials reporting on the effect of sealants (available on the U.S. market) when applied to the occlusal surfaces of primary and permanent molars. The authors used the Grading of Recommendations Assessment, Development, and Evaluation approach to assess the quality of the evidence and to move from the evidence to the decisions.

RESULTS

The guideline panel formulated 3 main recommendations. They concluded that sealants are effective in preventing and arresting pit-and-fissure occlusal carious lesions of primary and permanent molars in children and adolescents compared with the nonuse of sealants or use of fluoride varnishes. They also concluded that sealants could minimize the progression of non-cavitated occlusal carious lesions (also referred to as initial lesions) that receive a sealant. Finally, based on the available limited evidence, the panel was unable to provide specific recommendations on the relative merits of 1 type of sealant material over the others. Conclusions and practical implications: These recommendations are designed to inform practitioners during the clinical decision-making process in relation to the prevention of occlusal carious lesions in children and adolescents. Clinicians are encouraged to discuss the information in this guideline with patients or the parents of patients. The authors recommend that clinicians re-orient their efforts toward increasing the use of sealants on the occlusal surfaces of primary and permanent molars in children and adolescents.

Leading the Dental Quality Movement: A Dental Quality Alliance Perspective

Changing regulatory priorities set forth by the Affordable Care Act and recent activities of the Centers for Medicare and Medicaid Services clearly prioritize the need to improve the quality of health care in both the public and private sectors. As the largest multistakeholder organization focused on oral health care quality measurement and improvement, the Dental Quality Alliance is leading the way in establishing standardized and valid quality measures applicable in both private and public sectors.

Dental Students' Use of AMSTAR to Critically Appraise Systematic Reviews

The idea of basing clinical procedures upon evidence gathered by observation is less than 200 years old, with the first set of evidence-based position papers dating back only to the early 1970s. The relationship between evidence-based education and health outcomes is difficult to test and may be indirect, but teaching critical appraisal skills may be beneficial in developing knowledge. Systematic reviews have a central role in the process of clinical decision making in practice and therefore should be of high quality, following a rigorous protocol that can be evaluated with validated tools. The aim of this study was to assess how dental students utilized the Assessment of Multiple Systematic Reviews (AMSTAR) appraisal tool to evaluate systematic reviews in the context of a treatment planning course. During the in-class final exam, students were required to appraise the quality of a systematic review and to justify their answers. Of the 74 third-year students who took the exam, 100% answered all questions on the AMSTAR form. The mean number of correct answers was nine (SD=1.047, Min=6, Max=10), with no student providing all 11 correct answers. The fact that nearly 90% of the students provided eight or more correct answers suggests that AMSTAR can be used by students to evaluate the methodological quality of systematic reviews. It also was evident that although the AMSTAR tool requires less than 15 minutes to complete an evaluation, using it requires extensive training and repetition to achieve consistent and reliable results.

A practical approach to evidence-based dentistry: VI: How to use a systematic review

BACKGROUND AND OVERVIEW

Dental practitioners face new clinical challenges on a daily basis. New treatment options and diagnostic tools are disseminated quickly, and the volume of articles and new evidence is overwhelming. Systematic reviews summarize and synthesize the available evidence related to diagnosis, therapy, prognosis, and harm for clinicians, patients, and decision makers. Such reviews represent one of the most powerful tools to translate knowledge into action.

PRACTICAL IMPLICATIONS

The critical appraisal of this type of study involves assessing the risk of bias, results, and applicability of such study. The authors provide guidance for clinicians to critically appraise systematic reviews and apply the findings in clinical practice.

Methodological quality and implications for practice of systematic Cochrane reviews in pediatric oral health: a critical assessment

BACKGROUND

To ensure evidence-based decision-making in pediatric oral health, Cochrane systematic reviews that address topics pertinent to this field are necessary. We aimed to identify all systematic reviews of paediatric dentistry and oral health by the Cochrane Oral Health Group (COHG), summarize their characteristics and assess their methodological quality. Our second objective was to assess implications for practice in the review conclusions and provide an overview of clinical implications about the usefulness of paediatric oral health interventions in practice.

METHODS

We conducted a methodological survey including all paediatric dentistry reviews from the COHG. We extracted data on characteristics of included reviews, then assessed the methodological quality using a validated 11-item quality assessment tool (AMSTAR). Finally, we coded each review to indicate whether its authors concluded that an intervention should be implemented in practice, was not supported or was refuted by the evidence, or should be used only in research (inconclusive evidence).

RESULTS

We selected 37 reviews; most concerned the prevention of caries. The methodological quality was high, except for the assessment of reporting bias. In 7 reviews (19%), the research showed that benefits outweighed harms; in 1, the experimental intervention was found ineffective; and in 29 (78%), evidence was insufficient to assess benefits and harms. In the 7 reviews, topical fluoride treatments (with toothpaste, gel or varnish) were found effective for permanent and deciduous teeth in children and adolescents, and sealants for occlusal tooth surfaces of permanent molars.

CONCLUSIONS

Cochrane reviews of paediatric dentistry were of high quality. They provided strong evidence that topical fluoride treatments and sealants are effective for children and adolescents and thus should be implemented in practice. However, a substantial number of reviews yielded inconclusive evidence.

Evidence-based prosthodontics: fundamental considerations, limitations, and guidelines

Evidence-based dentistry is rapidly emerging to become an integral part of patient care, dental education, and research. Prosthodontics is a unique dental specialty that encompasses art, philosophy, and science and includes reversible and irreversible treatments. It not only affords good applicability of many principles of evidence-based dentistry but also poses numerous limitations. This article describes the epidemiologic background, fundamental considerations, scrutiny of levels of evidence, limitations, guidelines, and future perspectives of evidence-based prosthodontics. Understanding these principles can aid clinicians in appropriate appraisal of the prosthodontics literature and use the best available evidence for making confident clinical decisions and optimizing patient care.

Changes in orthodontic treatment modalities in the past 20 years: exploring the link between technology and scientific evidence

STATEMENT OF THE ISSUE: Is there a link between the many perceived advances in orthodontic techniques/therapy and science in the past 20 years? The purpose of this paper is to take five topics and match the perceptions with the scientific evidence. The variety of appliances and the swings in treatment philosophy have been dramatic, including the swing from extraction to non-extraction therapy, the introduction of space-age wires, appliances that grow mandibles, the introduction and extraordinary growth of Invisalign, and reduced friction brackets to reduce treatment time, all with claims by manufacturers of better results than ever before. The focus is on faster treatment, reduced visits/appointments and superior results. Most of these 'advancements' represent what has been the 'juggernaut of technology'. Five questions are posed, and an evidence-based approach is used to critically examine the literature in these selected topics.

The development of evidence-based guidelines in dentistry

Use of guidelines is an important means of reducing the gap between research and clinical practice. Sound and unbiased information should be available to enable dental professionals to provide better clinical treatment for their patients. The development of clinical guidelines in dentistry should follow standard and transparent methodology. The purpose of this article is to propose important steps for developing evidence-based clinical recommendations in dentistry. Initially, dental guidelines should be extensively sought and assessed to answer focused clinical questions. If there is a paucity of guidelines or if existing guidelines are not of good methodological quality, systematic reviews should be searched or conducted to serve as a basis for the development of evidence-based guidelines. When systematic reviews are produced, they should be rigorous in order to provide the best evidence possible. In the last phase of the process, the overall quality of evidence should be scrutinized and assessed, together with other factors (balance between treatment effects and side effects, patients' values, and cost-effectiveness of therapy) to determine the strength of recommendations. It is expected this approach will result in the development of sound clinical guidelines and consequent improvement of dental treatment.

Inter-examiner reliability of salivary diagnostic tests in a practice-based research network

PURPOSE

Patient salivary characteristics are being measured as part of the Northwest PRECEDENT (Practice-based REsearch Collaborative in Evidence-based DENTistry) study on caries risk assessment. Prior to the implementation of these salivary diagnostic tests in a practice-based cohort study, inter-examiner reliability was assessed for resting salivary pH, stimulated salivary flow rate, pH and buffering capacity.

METHODS

An initial evaluation of inter-examiner reliability of the 4 salivary tests was conducted among 6 dental auxiliary examiners using a convenience sample of 40 dental students. An in complete block design was used to assign samples to examiners (3 examiners per sample and 20 samples per examiner). Inter-examiner reliability testing was conducted on a patient population representative of the practice-based network in 4 member practices. Two dental assistants per practice independently conducted the salivary tests on samples provided by a random selection of 20 to 25 patients. A separate analysis was performed for each study. For each test, an inter-examiner reliability index was computed.

RESULTS

Results from two studies are reported. In the first, stimulated salivary flow rate demonstrated excellent inter-examiner reliability, and resting salivary pH showed high inter-examiner reliability, while buffering capacity and stimulated salivary pH had moderate and very low inter-examiner reliability, respectively. In the second, inter-examiner reliability was excellent for the stimulated salivary flow rate and the resting salivary pH. The inter-examiner reliability for the stimulated salivary pH was also high and the stimulated salivary buffering capacity test had moderate reliability.

CONCLUSION

The small variance in stimulated salivary pH and buffering capacity in dental students may have artificially made the reliability appear low in the first attempt at inter-examiner reliability testing. In the second study, all 4 tests had an accept able performance.

Assessing the risk of bias in randomized controlled trials in the field of dentistry indexed in the Lilacs (Literatura Latino-Americana e do Caribe em Ciências da Saúde) database

CONTEXT AND OBJECTIVE

Well-conducted randomized controlled trials (RCTs) represent the highest level of evidence when the research question relates to the effect of therapeutic or preventive interventions. However, the degree of control over bias between RCTs presents great variability between studies. For this reason, with the increasing interest in and production of systematic reviews and meta-analyses, it has been necessary to develop methodology supported by empirical evidence, so as to encourage and enhance the production of valid RCTs with low risk of bias. The aim here was to conduct a methodological analysis within the field of dentistry, regarding the risk of bias in open-access RCTs available in the Lilacs (Literatura Latino-Americana e do Caribe em Ciências da Saúde) database.

DESIGN AND SETTING

This was a methodology study conducted at Universidade Federal de São Paulo (Unifesp) that assessed the risk of bias in RCTs, using the following dimensions: allocation sequence generation, allocation concealment, blinding, and data on incomplete outcomes.

RESULTS

Out of the 4,503 articles classified, only 10 studies (0.22%) were considered to be true RCTs and, of these, only a single study was classified as presenting low risk of bias. The items that the authors of these RCTs most frequently controlled for were blinding and data on incomplete outcomes.

CONCLUSION

The effective presence of bias seriously weakened the reliability of the results from the dental studies evaluated, such that they would be of little use for clinicians and administrators as support for decision-making processes.

Critical appraisal of methods used in randomized controlled trials of treatments for temporomandibular disorders

AIMS

To evaluate the quality of methods used in randomized controlled trials (RCTs) of treatments for management of pain and dysfunction associated with temporomandibular muscle and joint disorders (TMJD) and to discuss the implications for future RCTs.

METHODS

A systematic review was made of RCTs that were implemented from 1966 through March 2006, to evaluate six types of treatments for TMJD: orthopedic appliances, occlusal therapy, physical medicine modalities, pharmacologic therapy, cognitive-behavioral and psychological therapy, and temporomandibular joint surgery. A quality assessment of 210 published RCTs assessing the internal and external validity of these RCTs was conducted using the Consolidated Standards of Reporting Trials (CONSORT) criteria adapted to the methods of the studies.

RESULTS

Independent assessments by raters demonstrated consistency with a mean intraclass correlation coefficient of 0.63 (95% confidence interval). The mean percent of criteria met was 58%, with only 10% of the RCTs meeting the four most important criteria.

CONCLUSIONS

Much of the evidence base for TMJD treatments may be susceptible to systematic bias and most past studies should be interpreted with caution. However, a scatter plot of RCT quality versus year of publication shows improvement in RCT quality over time, suggesting that future studies may continue to improve methods that minimize bias.

[Acceptance of dental care guidelines by quality circles]

The discussion about the advantages of evidence-based guidelines in daily dental practice is a matter of current interest. In this report three high-quality S3 level pilot guidelines which have been developed in dental medicine were evaluated under practice conditions. Quality circles in the city of Hamburg readily accepted to join this survey. By means of a questionnaire before and after a 4-month field test in dental practices the participants of quality circles were interviewed about their attitude towards guidelines and to the application of the guidelines. In addition, the experience gained with the application of the guidelines was incorporated into a group discussion with moderators of quality circles. The inclusion of quantitative and qualitative methods enabled a recording of the complete range of differentiated opinions concerning the application of guidelines. The results show that the concerns expressed by participants can be reduced by integrating guidelines in their everyday clinical practice. A strength and weakness analysis demonstrates that the quality circle moderators' attitudes towards approved guidelines range from rather positive to ambivalent. Field testing by quality circles proves to be a sound method for evaluating the acceptance of guidelines in daily practice.

Dental practice network of U.S. dental schools

As dental schools incorporate training in evidence-based dentistry (EBD) into their curricula, students must learn how to critically evaluate systematic reviews and meta-analyses. It is important that dental education in the United States support the American Dental Association's position statement on EBD, which defines "best evidence" as data obtained from all study designs. Given that much evidence is missing when EBD is derived from Cochrane Systematic Reviews' randomized clinical trials, we propose the creation of a dental practice network of U.S. dental schools. We developed an electronic clinical dentistry research database for EBD using Epi-Info (available at www.cdc.gov/epiinfo/downloads.htm). As a free, public use software, Epi-Info provides the foundation for the development of clinical research databases that can increase the research capacity through multisite studies designed to generate outcomes data on the effectiveness of dental treatment. The creation of a dental practice network of dental schools with their large number of patients would expand the research capacity for EBD practice and advance the EBD science regarding the effectiveness of dental treatment. The next step is to link clinical dental researchers/educators at multiple dental schools through a collaborative clinical research network, so that the findings can be applied to the EBD component of problem-based learning curricula of dental education.

A guide to the appraisal of research: 1. The nature of research

Evidence-based dentistry has grown in recent years. The oceans of journals and research papers can be difficult to navigate. Gauging the quality of such publications and, more importantly, their clinical relevance may be challenging.This narrative review explores the nature and relevance of dental research to clinical dentistry and provides simple guidelines for critical appraisal of such research. In this respect, all dental clinical practice should be underpinned, where possible, with evidence that treatments carried out are contemporary and effective.

CLINICAL RELEVANCE

A working knowledge of dental research and its relevance to clinical practice should allow practitioners to select best evidence to inform their clinical practice.

GRADING--levels of evidence

As this journal changes, it is worth highlighting one the key elements of the Summaries we publish in Evidence-based Dentistry, namely the assignment of levels of evidence.Evidence-Based Dentistry (2009) 10, 24-25. doi:10.1038/sj.ebd.6400636.