Faculty Bibliography

The IADR Global Oral Health Inequalities Task Group on Dental Caries has synthesized current evidence and opinion to identify a five-year implementation and research agenda which should lead to improvements in global oral health, with particular reference to the implementation of current best evidence as well as integrated action to reduce caries and health inequalities between and within countries. The Group determined that research should: integrate health and oral health wherever possible, using common risk factors; be able to respond to and influence international developments in health, healthcare, and health payment systems as well as dental prevention and materials; and exploit the potential for novel funding partnerships with industry and foundations. More effective communication between and among the basic science, clinical science, and health promotion/public health research communities is needed. Translation of research into policy and practice should be a priority for all. Both community and individual interventions need tailoring to achieve a more equal and person-centered preventive focus and reduce any social gradient in health. Recommendations are made for both clinical and public health implementation of existing research and for caries-related research agendas in clinical science, health promotion/public health, and basic science.

DATA SOURCES: Medline, Cochrane Database of Systematic Reviews (CDSR), Database of Abstracts of Reviews of Effects (DARE), CINAHL, Science Direct, ISI Web of Science, and SCOPUS. The following journals were hand searched: Journal of Periodontology, International Journal of Periodontics and Restorative Dentistry, Journal of Clinical Periodontology, Journal of Dental Research, Journal of Periodontal Research, Periodontology 2000, Journal of Dentistry, Journal of American Dental Associations, Journal of Clinical Dentistry, Lasers in Medical Science, Lasers in Surgery and Medicine, Clinical Oral Investigations, and Photomedicine and Laser Surgery as well as the reference lists of included articles. STUDY SELECTION: Randomised controlled clinical trials (RCTs) comparing Er:YAG laser with manual or ultrasonic SRP alone were included. No language restrictions were applied. DATA EXTRACTION AND SYNTHESIS: Data were collected by two independent reviewers with only numeric data being extracted. Data were combined for meta-analysis with the effect size being estimated and reported as the mean difference (MD) for continuous variables using a random effects model. Heterogeneity was assessed using the /2-based Q-statistic method and I(2) measurement. RESULTS: Five trials met the inclusion criteria. Five trials (85 patients and 3,564 sites) were entered in the meta-analysis to investigate clinical attachment level (CAL) gain, pocket depth (PD) reduction and gingival recession (GR). All studies reported significant intragroup improvement in clinical and microbiological parameters in patients treated with the Er:YAG laser. However, three studies did not report a significant difference between Er:YAG laser and SRP groups in CAL gain, PD reduction or GR changes. The meta-analysis revealed no significant differences for any investigated parameters at six and 12 months. CONCLUSIONS: Significant heterogeneity, a high risk of bias in three of the five included studies, and methodological shortcomings indicate that the results should be considered with caution. Future long-term, well-designed RCTs are needed to assess the scientific evidence of Er:YAG laser efficacy as an alternative treatment strategy to SRP.

DATA SOURCES: Medline, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL) and hand searching of the journals; Community Dentistry and Oral Epidemiology, Gerodontology, Journal of Clinical Periodontology, Journal of Dental Research, Journal of Periodontology, Journal of Periodontal Research, Journal of Public Health Dentistry and Oral Diseases. Any potential studies in the reference lists of the identified articles read completely were also considered. STUDY SELECTION: Studies published in English investigating associations between smoking and tooth loss and reporting the effect size were included. Literature reviews and studies that combined former smokers with non-smokers or current smokers were excluded. DATA EXTRACTION AND SYNTHESIS: Data were extracted by one reviewer and verified independently by another with disagreements being resolved by discussion. Methodological quality of studies was assessed using the modified Newcastle-Ottawa Scale (NOS). A qualitative summary is presented. RESULTS: Six cross-sectional and two cohort studies were included examining 58,755 subjects in four countries. All studies reported significant associations, although the strength of the association was usually moderate. Four studies reported dose-response relationships between exposure to smoking and the risk of developing tooth loss. A decrease in the risk of tooth loss for former smokers was evident in six studies. Interpretation of evidence for each element was consistent, despite some shortcomings regarding study type and population. CONCLUSIONS: Based on the consistent evidence found with the existing biological plausibility, a causal association between smoking and tooth loss is highly likely. Further studies using a cohort design and different populations are necessary to confirm this association.

DESIGN: A randomised controlled trial (RCT) was conducted. INTERVENTION: Women found to have a periodontal disease were randomly allocated to receive periodontal treatment in midpregnancy (this was the treatment group; n = 542) or after the pregnancy was concluded (the control group; n = 540). Periodontal disease was defined as presence of periodontal pockets of 4 mm or greater in depth at 12 or more probing sites in fully erupted teeth (typically excluding wisdom teeth). Treatments were conducted either by the hygienists or periodontists and included nonsurgical debridement of the subgingival and supragingival plaque, removal of local predisposing factors such as calculus, root planing, and adjustment of overhanging restorations. Comprehensive oral hygiene instructions and motivation were provided at each visit at a minimum of three weekly visits, with further visits if required. OUTCOME MEASURE: The primary outcomes were preterm birth or other major complications of pregnancy. RESULTS: There were no differences between the control and treatment groups in terms of: preterm birth [9.3% compared with 9.7%; odds ratio (OR), 1.05; 95% confidence interval (CI), 0.7-1.58; P 0.81); birthweight (3450 g versus 3410 g; P 0.12); pre-eclampsia (4.1% versus 3.4%; OR, 0.82; 95% CI, 0.44-1.56; P 0.55); or other obstetric endpoints. There were four unexplained stillbirths in the control group and no pregnancy losses in the treated group (P 0.12). Measures of foetal and neonatal wellbeing were similar in the two groups, including abnormalities in foetal heart rate recordings (P 0.26), umbilical artery flow studies (P 0.96), and umbilical artery blood gas values (P 0.37). The periodontal treatment was highly successful in improving health of the gums (P<0.01). CONCLUSIONS: The evidence provided by the present study does not support the hypothesis that treatment of periodontal disease during pregnancy in this population prevents preterm birth, foetal growth restriction, or pre-eclampsia. Periodontal treatment was not hazardous to the women or their pregnancies.

DATA SOURCES: Studies were sourced using Biomed Central, Cochrane Oral Health Reviews, the Cochrane Library, Directory of Open Access Journals, Expanded ASAP Plus, the MetaRegister of Controlled Trials (www.controlled-trials.com/), Medline (PubMed) Science-Direct, Research Findings Electronic Register, and BBO/LILACS. STUDY SELECTION: Clinical trials and systematic reviews relevant to the review objective published in English, German, Portuguese or Spanish were included after independent review by two reviewers; disagreements were resolved by discussion and consensus. DATA EXTRACTION AND SYNTHESIS: Data extraction and quality assessment was undertaken independently in duplicate by two reviewers. The outcome measure for the caries preventive effect was caries-absence on sealed teeth. A meta-analysis was conducted. RESULTS: Out of 25 selected studies, 11 met the inclusion criteria (eight were trials and three were systematic reviews) with six of these being included in a meta-analysis. The pooled odds ratio was 0.96 (95% confidence interval, 0.62-1.49), indicating no difference in the caries-preventive effect of glass ionomer cements (GIC) and resin-based fissure sealant material. CONCLUSIONS: GIC and resin-based sealants exhibited significant caries-preventive effects. This review found no evidence that either material was superior to the other in the prevention of caries. Therefore both materials appear to be equally suitable as fissure sealant materials.

The ultimate goal of evidence-based health care (EBH) and evidence-based dentistry (EBD) is the improvement of health of our patients, our practices, and our families. The mechanics of balancing these in the face of overwhelming and increasing information is a challenge. With this challenge come the benefits of access to knowledge that can improve health, the legal risks for inattention, and arguments to the contrary. This conceptual introduction does not provide the truth--it provides one viewpoint. Clinicians will need to decide for themselves if and when they might (or might not) chose to embrace an evidence-based approach to healthcare improvement.