Faculty Bibliography

The antimicrobial use of silver compounds pivots on the 100-year-old application of silver nitrate, silver foil, and silver sutures for the prevention and treatment of ocular, surgical, and dental infections. Ag(+) kills pathogenic organisms at concentrations of <50 ppm, and current/potential anti-infective applications include: acute burn coverings, catheter linings, water purification systems, hospital gowns, and caries prevention. To distill the current best evidence relative to caries, this systematic review asked: Will silver diamine fluoride (SDF) more effectively prevent caries than fluoride varnish? A five-database search, reference review, and hand search identified 99 human clinical trials in three languages published between 1966 and 2006. Dual review for controlled clinical trials with the patient as the unit of observation, and excluding cross-sectional, animal, in vitro studies, and opinions, identified 2 studies meeting the inclusion criteria. The trials indicated that SDF's lowest prevented fractions for caries arrest and caries prevention were 96.1% and 70.3%, respectively. In contrast, fluoride varnish's highest prevented fractions for caries arrest and caries prevention were 21.3% and 55.7%, respectively. Similarly, SDF's highest numbers needed to treat for caries arrest and caries prevention were 0.8 (95% CI=0.5-1.0) and 0.9 (95% CI=0.4-1.1), respectively. For fluoride varnish, the lowest numbers needed to treat for caries arrest and prevention were 3.7 (95% CI=3.4-3.9) and 1.1 (95% CI=0.7-1.4), respectively. Adverse events were monitored, with no significant differences between control and experimental groups. These promising results suggest that SDF is more effective than fluoride varnish, and may be a valuable caries-preventive intervention. As well, the availability of a safe, effective, efficient, and equitable caries-preventive agent appears to meet the criteria of both the WHO Millennium Goals and the US Institute of Medicine's criteria for 21st century medical care.

DATA SOURCES: The Cochrane Central Register of Controlled Trials, PubMed Medline and Latin American and Caribbean Health Science literature databases were searched, and searches made by hand of identified papers, to source relevant data. (BIOSIS Previews) were searched. There were no language restrictions. STUDY SELECTION: Studies were evaluated by two reviewers independently. Only clinical trials were included that were published in the English, Spanish and Portuguese languages and were performed on humans. Articles were excluded when the examiners were not calibrated; when they did not compare manual and electronic probing techniques; when they did not measure the clinical attachment level (CAL); and when the subjects did not present destructive periodontal disease or had already received periodontal treatment. DATA EXTRACTION AND SYNTHESIS: The quality of the identified studies was assessed and standardised data extracted. Only two studies met all the selection criteria so no meta-analysis was performed. RESULTS: Only two of the 37 identified articles were included in the review. The results of these two studies showed that the mean variance and the absolute mean difference between CAL measurements for the two types of probes were not statistically different. CONCLUSIONS: Manual and electronic probes were of similar reliability when used to measure CAL in individuals who had untreated periodontitis and when used by a calibrated examiner, but this finding is not supported by strong evidence.

BACKGROUND: Temporomandibular joint disorders (TMJD) are multifactor, complex clinical problems affecting approximately 60-70% of the general population, with considerable controversy about the most effective treatment. For example, reports claim success rates of 70% and 83% for non-surgical and surgical treatment, whereas other reports claim success rates of 40% to 70% for self-improvement without treatment. Therefore, the purpose of this study was to (1) identify systematic reviews comparing temporomandibular joint disorder surgical and non-surgical treatment, (2) evaluate their methodological quality, and (3) evaluate the evidence grade within the systematic reviews. METHODS: A search strategy was developed and implemented for MEDLINE, Cochrane Library, LILACS, and Brazilian Dentistry Bibliography databases. Inclusion criteria were: systematic reviews (+/- meta-analysis) comparing surgical and non-surgical TMJD treatment, published in English, Spanish, Portuguese, Italian, or German between the years 1966 and 2007(up to July). Exclusion criteria were: in vitro or animal studies; narrative reviews or editorials or editorial letters; and articles published in other languages. Two investigators independently selected and evaluated systematic reviews. Three different instruments (AMSTAR, OQAQ and CASP) were used to evaluate methodological quality, and the results averaged. The GRADE instrument was used to evaluate the evidence grade within the reviews. RESULTS: The search strategy identified 211 reports; of which 2 were systematic reviews meeting inclusion criteria. The first review met 23.5 +/- 6.0% and the second met 77.5 +/- 12.8% of the methodological quality criteria (mean +/- sd). In these systematic reviews between 9 and 15% of the trials were graded as high quality, and 2 and 8% of the total number of patients were involved in these studies. CONCLUSION: The results indicate that in spite of the widespread impact of TMJD, and the multitude of potential interventions, clinicians have expended sparse attention to systematically implementing clinical trial methodology that would improve validity and reliability of outcome measures. With some 20 years of knowledge of evidence-based healthcare, the meager attention to these issues begins to raise ethical issues about TMJD trial conduct and clinical care.

BACKGROUND: The authors describe and evaluate the short-term effectiveness of a community-based program for dental caries prevention in children. METHODS: The authors enrolled pupils in the ForsythKids program after receiving informed consent. They targeted children at six Massachusetts elementary schools, grades 1 through 3, with pupil populations at high risk of developing caries. The children underwent examination by dentists using calibrated technique and received comprehensive preventive care from dental hygienists. The authors determined effectiveness by means of comparing results of the initial examination with those of a second examination performed six months later. RESULTS: At baseline, 70 percent of the 1,196 participating children had decayed or filled teeth. More troublingly, 42.1 percent of the primary teeth and 31.1 percent of the permanent teeth had untreated decay. Six months after preventive intervention, the proportion of teeth with new decay was reduced 52 percent in primary teeth and 39 percent in permanent teeth. Furthermore, the percentage of children with newly decayed or restored primary and permanent teeth was reduced by 25.4 percent and 53.2 percent, respectively. CONCLUSIONS: These results indicate that this care model relatively quickly can overcome multiple barriers to care and improve children's oral health. CLINICAL IMPLICATIONS: If widely implemented, comprehensive caries prevention programs such as ForsythKids could accomplish national health goals and reduce the need for new care providers and clinics.

DATA SOURCES: Medline and the Cochrane Central Register of Controlled Trials were used to identify sources of data. STUDY SELECTION: Title and abstracts were screened independently. Randomised controlled clinical trials of >6 months duration that used gingivitis or plaque levels as outcome measures were selected. DATA EXTRACTION AND SYNTHESIS: The mean values and standard deviations were extracted. In studies where standard errors of the mean were reported, standard deviations were calculated by the authors based on the sample size. Weighted means of baseline and of end of trial were calculated with the software Cochrane Collaboration Review Manager (version 4.2; The Cochrane Collaboration, Oxford, England) using a random-effects model. A meta-analysis for stannous fluoride (SnF) mouth rinse and dentifrice/ mouthrinse formulations was not performed because there were insufficient data. RESULTS: Fifteen papers were included in the review. For SnF dentifrices, a statistically significant reduction in gingivitis was noted in comparison with control [weighted mean difference (WMD), 0.15 (gingival index) and 0.21 (gingivitis severity index); test for heterogeneity P<0.00001, I(2)=91.1% and P 50.03, I(2)= 80.1%, respectively]. There were inconsistent results for plaque reduction. On using the plaque index, no differences were found, whereas meta-analysis of the Turesky index gave a WMD of 0.31 (P 50.01; test for heterogeneity P 0.0001, I(2)=91.7%). CONCLUSIONS: The use of SnF dentifrices results in greater gingivitis and plaque reduction compared with a conventional dentifrice. The precise magnitude of this effect was difficult to assess because of a high level of heterogeneity in study outcomes.

DESIGN: This was a randomised, placebo-controlled trial with 6 months of follow-up. INTERVENTION: Patients received nonsurgical periodontal therapy and 3 months of the test treatment (low-dose doxycycline; LDD) or control (inactive identical placebo). OUTCOME MEASURE: The primary outcome was the change in the clinical attachment level (CAL) recorded from the cemento-enamel junction to the base of the probing pocket using a graduated UNC-15 probe (Hu Friedy, Chicago, Illinois, USA). Secondary outcomes included pocket depth, gingival recession and bleeding on probing recorded at six sites per tooth with the manual probe and ICTP (terminal carboxytelopeptide of type 1 collagen). RESULTS: The velocity of change was statistically significantly greater for the test group for CAL [-0.19 mm/ month; 95% confidence interval (CI), -0.34- -0.04; P 0.012] and probing depth (0.30 mm/ month; 95% CI, -0.42- -0.17; P 0.001). No differences were observed, however, for absolute change in clinical or biochemical markers at 6 months. CONCLUSIONS: Nonsurgical periodontal therapy in smokers can produce a substantial improvement in periodontal health but there is no evidence to support the use of LDD as an adjunct to their nonsurgical therapy. Quitting tobacco use continues to be of fundamental importance in improving the periodontal health of these individuals.

DATA SOURCES: The Cochrane Oral Health Group's Trials Register, Cochrane Central Register of Controlled Trials, Medline, Embase, Psychinfo, Ingenta and Cumulative Index to Nursing and Allied Health Literature were searched, along with the reference lists from relevant articles. The authors of eligible trials were contacted to identify further studies and obtain additional information. Four journals were searched by hand (Journal of Health Psychology, Psychology and Health, Psychology Health and Medicine, Health Psychology - Update). No language restriction was applied. STUDY SELECTION: Randomised controlled trials were selected that tested the effectiveness of interventions based on psychological models, comparing them with educational, attention or no active intervention controls, to improve adherence to oral hygiene in adults with either gingivitis or periodontitis. Only trials with at least 3 weeks' followup were included. Interventions aimed at encouraging smoking cessation were not included. DATA EXTRACTION AND SYNTHESIS: Titles and abstracts of studies that were potentially relevant to the review were independently screened by two review authors. Those that were clearly ineligible were rejected. For the remaining studies, the full paper was reviewed by two review authors and, where necessary, further information was sought from the author to verify eligibility. The quality of included studies was assessed using standard criteria. RESULTS: Four studies (of 344 participants) were found in which a psychological model or theory had been explicitly used as the basis for the design of the intervention. The overall quality of trials was low. Because of the heterogeneity of studies, both in terms of outcome measures and psychological models adopted, a meta-analysis was not possible. The four studies adopted four different theoretical frameworks, although there was some overlap in that three of the studies incorporated elements of Operant and Classical Conditioning. Psychological interventions resulted in improved plaque scores compared with no-intervention groups, and in one study compared with an attention control group. One study found decreased gingival bleeding in the active intervention group but no change in pocket depth or attachment loss after 4 months. Psychological interventions were associated with improved self-reported brushing and flossing in both the studies that assessed these behaviours. Only one study explored the impact of psychological interventions on beliefs and attitudes: the psychological intervention, when compared with educational and no-intervention controls, showed improved self-efficacy beliefs in relation to flossing, but no effect on dental knowledge or self-efficacy beliefs in relation to tooth brushing. CONCLUSIONS: There is some evidence from low-quality studies that psychological approaches to behaviour management, such as the use of reinforcement, goal setting and the provision of feedback, can improve oral hygiene and oral hygiene-related behaviours. The design of the interventions was weak and limited, however, and ignored key aspects of the theories. All the studies reported here also relied upon the provision of guidance by personnel other than the practitioner. There is no evidence that the use of such an approach by the practitioner with his or her patients would be beneficial. Thus, there is a need for greater methodological rigour in the design of trials in this area.