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New Cochrane Systematic Reviews - Cochrane Oral Health Group
New Cochrane Systematic Reviews – Cochrane Oral Health Group The Cochrane Oral Health Group in Issues 1, January, and Issue 2, April, 2004 of The Cochrane Library published 7 new systematic reviews and 2 review updates. The abstracts for these reviews are below. For a full list of reviews/protocols published by the Cochrane Oral Health Group, please visit their website (www.cochrane-oral.man.ac.uk).
DIRECT VERSUS INDIRECT VENEER RESTORATIONS FOR INTRINSIC DENTAL STAINS (Cochrane Review) Wakiaga J, Brunton P, Silikas N, Glenny AM
T HE C OCHRANE R EVIEWS Abstract
BACKGROUND: Patients with discoloured teeth frequently present to the dentist requesting restorations designed to improve their appearance. For teeth that are sound, this might include the use of a veneer restoration. The veneer acts as a thin layer of a material covering the labial surface of a tooth and can be applied directly to the tooth, or by using indirect methods.
either composite or porcelain. The primary outcome was restoration failure.
OBJECTIVES: To examine the effectiveness of direct versus indirect laminate veneer restorations.
MAIN RESULTS: Six full publications were screened as being potentially relevant to the review, only 1 trial was found to meet the review’s inclusion criteria. Although the trial met the review’s inclusion criteria with regard to participant characteristics, interventions and outcomes assessed, problems with the reporting of the data prevented any statistical analysis of the results.
SEARCH STRATEGY: The following electronic databases were searched: The Cochrane Oral Health Group’s Trials Register, The Cochrane Central Register of Controlled Trials (CENTRAL), (The Cochrane Library Issue 3, 2002), MEDLINE (1980 to 19/11/2002), and EMBASE (1980 to 19/ 11/2002). There was no restriction on language. SELECTION CRITERIA: All randomised controlled trials (RCTs) of participants with permanent anterior teeth suitable for restorations using laminate veneers, comparing direct (different composite materials) and indirect techniques for making dental veneers. The indirect restorations may be
DATA COLLECTION & ANALYSIS: Assessment of relevance and validity and data extraction were conducted in triplicate. Authors of the primary studies were contacted to provide additional information as necessary.
REVIEWERS’ CONCLUSIONS: There is no reliable evidence to show a benefit of one type of veneer restoration (direct or indirect) over the other with regard to the longevity of the restoration. Citation: Wakiaga J, Brunton P, Silikas N, Glenny AM. Direct versus indirect veneer restorations for intrinsic dental stains (Cochrane Review). In: The Cochrane Library, Issue 1, 2004. Chichester, UK: John Wiley & Sons, Ltd.
J Evid Base Dent Pract 2004;2:181-8 D 2004 Mosby, Inc. All rights reserved. doi:10.1016/j.jebdp.2004.04.001
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RETENTION PROCEDURES FOR STABILISING TOOTH POSITION AFTER TREATMENT WITH ORTHODONTIC BRACES (Cochrane Review) Littlewood SJ, Millett DT, Doubleday B, Bearn DR, Worthington HV
BACKGROUND: Retention is the phase of orthodontic treatment that attempts to keep teeth in the corrected positions after orthodontic (dental) braces. Without a phase of retention there is a tendency for the teeth to return to their initial position (relapse). To prevent relapse, almost every patient who has orthodontic treatment will require some type of retention. OBJECTIVES: To evaluate the effectiveness of different retention strategies used to stabilize tooth position after orthodontic braces. SEARCH STRATEGY: The Cochrane Oral Health Group’s Trials Register, CENTRAL, MEDLINE and EMBASE were searched. Several journals were handsearched. No language restrictions were applied. Authors of randomised controlled trials (RCTs) were identified and contacted to identify unpublished trials. Most recent search: December 2002. SELECTION CRITERIA: RCTs on children and adults, who have had retainers fitted or adjunctive procedures undertaken, following orthodontic treatment with braces to prevent relapse. The outcomes are: how well the teeth are stabilised, survival of retainers, adverse effects on oral health, and quality of life. DATA COLLECTION & ANALYSIS: Screening of eligible studies, assessment of the methodological quality of the trials and data extraction were conducted in duplicate and independently by 2 reviewers. Because no 2 studies compared the same
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retention strategies (interventions), it was not possible to combine the results of any studies.
MAIN RESULTS: Four trials satisfied the inclusion criteria. These trials all compared different interventions: circumferential supracrestal fiberotomy (CSF) combined with full-time removable retainer versus a full-time removable retainer alone; circumferential supracrestal fiberotomy (CSF) combined with a nights-only removable retainer versus a nights-only removable retainer alone; removable Hawley retainer versus a clear overlay retainer; and 3 types of fixed retainers versus a removable retainer. There was weak unreliable evidence, based on data from 1 trial, that there was a statistically significant increase in stability in both the mandibular (P < 0.001) and maxillary anterior segments (P < 0.001) when the CSF was used, compared with when it was not used. There was also weak, unreliable evidence that teeth settle quicker with a Hawley retainer than with a clear overlay retainer after 3 months. The quality of the trial reports was generally poor. REVIEWERS’ CONCLUSIONS: There are insufficient research data on which to base our clinical practice on retention at present. There is an urgent need for high quality randomised controlled trials in this crucial area of orthodontic practice. Citation: Littlewood SJ, Millett DT, Doubleday B, Bearn DR, Worthington HV. Retention procedures for stabilising tooth position after treatment with orthodontic braces (Cochrane Review). In: The Cochrane Library, Issue 1, 2004. Chichester, UK: John Wiley & Sons, Ltd.
Journal of Evidence-Based Dental Practice June 2004
STABILISATION SPLINT THERAPY FOR TEMPOROMANDIBULAR PAIN DYSFUNCTION SYNDROME (Cochrane Review) Al-Ani MZ, Davies SJ, Gray RJM, Sloan P, Glenny AM BACKGROUND: Pain dysfunction syndrome (PDS) is the most common temporomandibular disorder (TMD). There are many synonyms for this condition including facial arthromyalgia, TMJ dysfunction syndrome, myofascial pain dysfunction syndrome, craniomandibular dysfunction and myofascial pain dysfunction. The aetiology of PDS is multifactorial and many different therapies have been advocated. OBJECTIVES: To establish the effectiveness of stabilisation splint therapy in reducing symptoms in patients with pain dysfunction syndrome. SEARCH STRATEGY: Electronic databases (including the Cochrane Oral Health Group’s Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); The Cochrane Library Issue 2, 2003; MEDLINE (1966 to June 2001); EMBASE (1966 to June 2001)) were searched. Handsearching of relevant journals was undertaken and reference lists of included studies screened. Experts in the field were contacted to identify unpublished articles. There was no language restriction. SELECTION CRITERIA: Randomised or quasi-randomised controlled trials (RCTs), in which splint therapy was compared concurrently to no treatment, other occlusal appliances, or any other active intervention. DATA COLLECTION & ANALYSIS: Data extraction was carried out independently and in duplicate. Validity assessment of the included trials was carried out at the same time as data extraction.
Journal of Evidence-Based Dental Practice Volume 4, Number 2
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Discrepancies were discussed and a third reviewer consulted. The author of the primary study was contacted where necessary. The studies were grouped according to treatment type and duration of follow up.
MAIN RESULTS: Twenty potentially relevant RCTs were identified. Eight trials were excluded, leaving 12 RCTs for analysis. Stabilisation splint therapy was compared to acupuncture, bite plates, biofeedback/stress management, visual feedback, relaxation, jaw exercises, nonoccluding appliance, and minimal/no treatment. There was no evidence of a statistically significant difference in the effectiveness of stabilisation splint therapy in reducing symptoms in patients with pain dysfunction syndrome compared with other active treatments. There is weak evidence to suggest that the use of SS for the treatment of PDS may be beneficial for reducing pain severity, at rest and on palpation, when compared to no treatment. REVIEWERS’ CONCLUSIONS: There is insufficient evidence either for or against the use of stabilisation splint therapy for the treatment of temporomandibular pain dysfunction syndrome. This review suggests the need for further, well conducted RCTs that pay attention to method of allocation, outcome assessment, large sample size, and enough duration of follow up. A standardisation of the outcomes of the treatment of PDS should be established in the RCTs. Citation: Al-Ani MZ, Davies SJ, Gray RJM, Sloan P, Glenny AM. Stabilisation splint therapy for temporomandibular pain dysfunction syndrome (Cochrane Review). In: The Cochrane Library, Issue 1, 2004. Chichester, UK: John Wiley & Sons, Ltd.
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DOMESTIC VIOLENCE SCREENING AND INTERVENTION PROGRAMMES FOR ADULTS WITH DENTAL OF FACIAL INJURY (Cochrane Review) Coulthard P, Yong S, Adamson L, Warburton A, Worthington HV
BACKGROUND: Domestic violence exists in all communities across the world. Health care services have a pivotal role in the identification, assessment, and response to domestic violence. Because the face is a common target in assault, dentists and oral and maxillofacial surgeons are in a unique position to screen for domestic violence in the context of presentation of dental and facial injury. Owing to lack of training, dentists and oral and maxillofacial surgeons may not be the best persons to give advice to someone experiencing domestic violence. Improper advice, such as encouragement to leave an abusive relationship, may escalate the frequency of violence. It may be more appropriate to refer to specialist agencies for intervention and support. It would, therefore be useful to know whether screening and intervention programmes are effective. OBJECTIVES: (1) To assess the benefits and harms of intervention programmes employed to reduce and or prevent domestic violence in adults with dental and/or facial injuries. (2) To assess the benefits and harms of screening and the use of different screening tools in the detection of the proportion of adult victims of domestic violence who present with dental and/ or facial injury.
SEARCH STRATEGY: We searched the Cochrane Oral Health Group’s Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, PsycINFO, and Lilacs databases. No language restrictions were applied. Personal contacts were used and international domestic violence organisations were
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contacted to identify any unpublished trials. Last search was done February 2004.
SELECTION CRITERIA: Randomised controlled trials involving adults aged 16 years and over presenting with dental and/or facial injury relating to domestic violence in any health care setting. DATA COLLECTION & ANALYSIS: Screening of eligible studies was conducted in duplicate and independently by 2 reviewers. Results were to be expressed as random effects models using weighted mean differences for continuous outcomes and relative risk for dichotomous outcomes with 95% confidence interval. Heterogeneity was to be investigated including both clinical and methodological factors. MAIN RESULTS: No eligible randomised controlled trials (RCTs) were identified. REVIEWERS’ CONCLUSIONS: There is no evidence to support or refute that screening for domestic violence in adults with dental or facial injury is beneficial nor that it causes harm. Screening tools to detect domestic violence exist but no RCTs have specifically evaluated their effectiveness for patients presenting with facial and or dental injuries. There is also lack of evidence that intervention programmes are effective at reducing frequency of physical assaults and at reducing the severity of facial injuries. Citation: Coulthard P, Yong S, Adamson L, Warburton A, Worthington HV. Domestic violence screening and intervention programmes for adults with dental of facial injury (Cochrane Review). In: The Cochrane Library, Issue 2, 2004. Chichester, UK: John Wiley & Sons, Ltd.
Journal of Evidence-Based Dental Practice June 2004
PENICILLINS FOR THE PROPHYLAXIS OF BACTERIAL ENDOCARDITIS IN DENTISTRY (Cochrane Review) Oliver R, Roberts GJ, Hooper L BACKGROUND: Many dental procedures cause bacteraemia and it is believed that this may lead to bacterial endocarditis (BE) in a few people. Guidelines in many countries recommend that prior to invasive dental procedures antibiotics are administered to people at high risk of endocarditis. However, it is unclear whether the potential risks of this prophylaxis outweigh the potential benefits. OBJECTIVES: To determine whether prophylactic penicillin administration compared to no such administration or placebo before invasive dental procedures in people at increased risk of BE influences mortality, serious illness, or endocarditis incidence. SEARCH STRATEGY: The search strategy was developed on MEDLINE and adapted for use on the Cochrane Oral Health, Heart and Infectious Diseases Groups’ Trials Registers (to October 2003), as well as the following databases: Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 2, 2002), OLDMEDLINE (1966 to June 2002); EMBASE (1980 to June 2002); SIGLE (to June 2002); and the Meta-register of current controlled trials. SELECTION CRITERIA: Because of the low incidence of BE, it was anticipated that few if any trials would be located. For this reason, cohort and case-controlled studies were included in which suitably matched control or comparison groups had been studied. The intervention was the administration of penicillin compared to no such administration before a dental procedure in people with an increased risk of BE. Cohort studies would need to follow those at increased risk and assess outcomes following any invasive dental procedures, grouping by whether prophylaxis was received. Included casecontrol studies would need to match people who had developed endocarditis (and who were known to be at increased risk before undergoing an invasive dental procedure preceding the onset of endocarditis) with those at similar risk but who had not developed endocarditis. Outcomes of interest included mortality or serious adverse event requiring hospital admission, Journal of Evidence-Based Dental Practice Volume 4, Number 2
Abstract
development of endocarditis following any dental procedure in a defined time period, development of endocarditis due to other nondental causes, any recorded adverse events to the antibiotics, and cost implications of the antibiotic provision for the care of those patients who develop endocarditis.
DATA COLLECTION & ANALYSIS: Two reviewers independently selected studies for inclusion, then assessed quality and extracted data from the included study. MAIN RESULTS: No RCTs, CCTs or cohort studies were included. One case-control study met the inclusion criteria. It collected all the cases of endocarditis in the Netherlands over 2 years, finding a total of 24 people who developed endocarditis within 180 days of an invasive dental procedure, definitely requiring prophylaxis according to current guidelines and who were at increased risk of endocarditis due to a pre-existing cardiac problem. This study included participants who died because of the endocarditis (using proxys). Controls attended local cardiology outpatient clinics for similar cardiac problems, had undergone an invasive dental procedure within the past 180 days and were matched by age with the cases. No significant effect of penicillin prophylaxis on the incidence of endocarditis could be seen. No data were found on other outcomes. REVIEWERS’ CONCLUSIONS: There is no evidence about whether penicillin prophylaxis is effective or ineffective against bacterial endocarditis in people at risk who are about to undergo an invasive dental procedure. There is a lack of evidence to support published guidelines in this area. It is not clear whether the potential harms and costs of penicillin administration outweigh any beneficial effect. Ethically practitioners need to discuss the potential benefits and harms of antibiotic prophylaxis with their patients before a decision is made about administration. Citation: Oliver R, Roberts GJ, Hooper L. Penicillins for the prophylaxis of bacterial endocarditis in dentistry (Cochrane Review). In: The Cochrane Library, Issue 2, 2004. Chichester, UK: John Wiley & Sons, Ltd. Cochrane Reviews
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INTERVENTIONS FOR TREATING ORAL MUCOSITIS FOR PATIENTS WITH CANCER RECEIVING TREATMENT (Cochrane Review) Clarkson JE, Worthington HV, Eden OB
Review Updates BACKGROUND: Treatment of cancer is increasingly effective but is associated with short- and long-term side effects. Oral side effects, including oral candidiasis, remain a major source of illness despite the use of a variety of agents to treat them. OBJECTIVES: To assess the effectiveness of interventions for the treatment of oral candidiasis for patients with cancer receiving chemotherapy and/or radiotherapy. SEARCH STRATEGY: Computerised searches of Cochrane Oral Health Group’s Trials Register, CENTRAL, MEDLINE, and EMBASE were undertaken. Reference lists from relevant articles were searched and the authors of eligible trials were contacted to identify trials and obtain additional information. Date of the most recent searches: August 2003: (CENTRAL) (The Cochrane Library Issue 3, 2003). SELECTION CRITERIA: All randomised controlled trials comparing agents prescribed to treat oral candidiasis in people receiving chemotherapy or radiotherapy for cancer. The outcomes were eradication of oral candidiasis, dysphagia, systemic infection, amount of analgesia, length of hospitalisation, cost, and patient quality of life. DATA COLLECTION & ANALYSIS: Data were independently extracted, in duplicate, by 2 reviewers. Authors were contacted for details of randomisation and withdrawals and a quality assessment was carried out. The Cochrane Oral Health Group statistical guidelines were followed and relative risk
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values calculated using random effects models where significant heterogeneity was detected (P < 0.1).
MAIN RESULTS: Eight trials involving 418 patients, satisfied the inclusion criteria and are included in this review. Only 2 agents, each in single trials, were found to be effective for eradicating oral candidiasis. A drug absorbed from the gastrointestinal tract, ketoconazole, was more beneficial than placebo in eradicating oral candidiasis (relative risk [RR] = 0.35, 95% confidence interval (CI): 0.20– 0.61) and clotrimazole, at a higher dose of 50 mg was more effective than a lower 10-mg dose in eradicating oral candidiasis, when assessed mycologically (RR = 0.47, 95% CI: 0.25 –0.89). Another trial demonstrated no statistically significant difference between a 10-mg dose of the partially absorbed drug, clotrimazole, and placebo. No differences were found when comparing different absorbed drugs; and comparing absorbed drugs with drugs that are not absorbed. REVIEWERS’ CONCLUSIONS: There is weak and unreliable evidence that the absorbed drug, ketoconazole, may eradicate oral candidiasis and that a higher dose of the partially absorbed drug, clotrimazole, may give greater benefit than a lower 10-mg dose, however, researchers may wish to prevent rather than treat oral candidiasis. Further welldesigned, placebo-controlled trials assessing the effectiveness of old and new interventions for treating oral candidiasis are needed. Citation: Clarkson JE, Worthington HV, Eden OB. Interventions for treating oral candidiasis for patients with cancer receiving treatment (Cochrane Review). In: The Cochrane Library, Issue 1, 2004. Chichester, UK: John Wiley & Sons, Ltd.
Journal of Evidence-Based Dental Practice June 2004
INTERVENTIONS FOR TREATING ORAL CANDIDIASIS FOR PATIENTS WITH CANCER RECEIVING TREATMENT (Cochrane Review) Clarkson JE, Worthington HV, Eden OB BACKGROUND: Treatment of cancer is increasingly effective but associated with short- and long-term side effects. Oral side effects, including oral mucositis (mouth ulceration), remain a major source of illness despite the use of a variety of agents to treat them. OBJECTIVES: To assess the effectiveness of interventions for treating oral mucositis or its associated pain in patients with cancer receiving chemotherapy and/or radiotherapy. SEARCH STRATEGY: Computerised searches of Cochrane Oral Health Group’s Trials Register, CENTRAL, MEDLINE, and EMBASE were undertaken. Reference lists from relevant articles were searched and the authors of eligible trials were contacted to identify trials and obtain additional information. Date of the most recent searches August 2003: (CENTRAL) (The Cochrane Library Issue 3, 2003). SELECTION CRITERIA: All randomised controlled trials comparing agents prescribed to treat oral mucositis in people receiving chemotherapy and/or radiotherapy. Outcomes were oral mucositis, time to heal mucositis, oral pain, duration of pain control, dysphagia, systemic infection, amount of analgesia, length of hospitalisation, cost, and quality of life. DATA COLLECTION & ANALYSIS: Data were independently extracted, in duplicate, by reviewers. Authors were contacted for details of randomisation, blindness, and withdrawals. Quality assessment was carried out on these 3 criteria. The Cochrane Oral Health Group statistical guidelines were followed and relative risk values calculated using fixed effect models. MAIN RESULTS: Twenty five trials involving 1292 patients satisfied the inclusion criteria. Three agents, each in single trials, were found to be effective for improving (allopurinol
Journal of Evidence-Based Dental Practice Volume 4, Number 2
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RR 3.33, 95% CI: 1.06 –10.49; immunoglobulin RR 1.81, 95% CI: 1.24 –2.65; human placental extract RR 4.50, 95% CI: 2.29 –8.86) or eradicating mucositis (allopurinol RR 19.00, 95% CI: 1.17 –307.63). Two of these trials were rated as at moderate risk of bias and one as at high risk of bias. The following agents were not found to be effective: benzydamine HCl, sucralfate, tetrachlorodecaoxide, chlorhexidine, and ‘‘magic’’ (lidocaine solution, diphenhydramine hydrochloride, and aluminum hydroxide suspension). Six trials compared the time to heal and mucositis was found to heal more quickly with 2 interventions: granulocyte macrophage-colony stimulating factor when compared with povidone iodine, with mean difference 3.5 days (95% CI: 4.1 to 2.9) and allopurinol compared to placebo, with mean difference 4.5 days (95% CI: 5.8 to 3.2). Three trials compared patient controlled analgesia (PCA) to the continuous infusion method for controlling pain. There was no evidence of a difference, however, less opiate was used per hour for PCA, and the duration of pain was shorter. One trial demonstrated that pharmacokinetically based analgesia (PKPCA) reduced pain compared with PCA, however, more opiate was used with PKPCA.
REVIEWERS’ CONCLUSIONS: There is weak and unreliable evidence that allopurinol mouthwash, vitamin E, immunoglobulin, or human placental extract improve or eradicate mucositis. There is no evidence that patient-controlled analgesia (PCA) is better than continuous infusion method for controlling pain, however, less opiate was used per hour, and duration of pain was shorter, for PCA. Further, welldesigned, placebo-controlled trials assessing the effectiveness of allopurinol mouthwash, immunoglobulin, human placental extract, other interventions investigated in this review and new interventions for treating mucositis are needed. Citation: Clarkson JE, Worthington HV, Eden OB. Interventions for treating oral mucositis for patients with cancer receiving treatment (Cochrane Review). In: The Cochrane Library, Issue 2, 2004. Chichester, UK: John Wiley & Sons, Ltd.
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Cochrane News 12TH ANNUAL COCHRANE COLLOQUIUM: (2ND –6TH OCTOBER 2004, OTTAWA, CANADA) The 12th annual Cochrane Colloquium will take place in Ottawa, Canada from 2nd to 6th October 2004. The theme is ‘Bridging the Gaps’ i.e., the gaps between the Cochrane Collaboration and clinical practice, gaps between high and low-income countries and individuals, gaps between methodologists and reviewers, and gaps between producers and users of health care information. The scientific program of plenary sessions, workshops, papers and posters will address many of these gaps and offer helpful solutions. The target audience includes: 1. Current contributors to The Cochrane Collaboration, both newcomers and experienced members. 2. People with an interest in learning more about the organisation and its activities. 3. Potential partner organisations and institutions. 4. Health care policy makers, clinicians and consumers interested in the application of Cochrane systematic reviews to health policies, patient care, and personal decision-making.
EVIDENCE BASED PRACTICE IN DENTISTRY COURSE(7th –9th June 2004, Manchester, UK): A 3-day course for all dentists and members of the dental team is organised annually by the editorial team of the Cochrane Oral Health Group in Manchester, UK. The aim of the course is to provide the skills to implement an evidence-based care approach for effective clinical practice, audit, and research. The 3 days of workshops are complemented by distance learning, self-directed study, and mentored support, and at the end of the course the participants will be able to: 1. Understand the ideas and principles of evidencebased practice. 2. Identify clinical issues where assessment of the evidence would be helpful. 3. Search out and critically appraise relevant dental literature. 4. Concisely present the evidence on a clinical issue. 5. Interpret their findings and develop an implementation strategy, audit criteria, and/or research plan. The next course is to be held in June (7th –9th) 2004 and for further information visit www.cochrane-oral. man.ac.uk of contact [email protected]
The Cochrane Oral Health Group will be holding a meeting during the colloquium and cordially invites all those interested in learning more about the group and the Cochrane Collaboration. For further information visit: www.cochrane.org
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Journal of Evidence-Based Dental Practice June 2004
DIRECT VERSUS INDIRECT VENEER RESTORATIONS FOR INTRINSIC DENTAL STAINS (Cochrane Review) Wakiaga J, Brunton P, Silikas N, Glenny AM
T HE C OCHRANE R EVIEWS Abstract
BACKGROUND: Patients with discoloured teeth frequently present to the dentist requesting restorations designed to improve their appearance. For teeth that are sound, this might include the use of a veneer restoration. The veneer acts as a thin layer of a material covering the labial surface of a tooth and can be applied directly to the tooth, or by using indirect methods.
either composite or porcelain. The primary outcome was restoration failure.
OBJECTIVES: To examine the effectiveness of direct versus indirect laminate veneer restorations.
MAIN RESULTS: Six full publications were screened as being potentially relevant to the review, only 1 trial was found to meet the review’s inclusion criteria. Although the trial met the review’s inclusion criteria with regard to participant characteristics, interventions and outcomes assessed, problems with the reporting of the data prevented any statistical analysis of the results.
SEARCH STRATEGY: The following electronic databases were searched: The Cochrane Oral Health Group’s Trials Register, The Cochrane Central Register of Controlled Trials (CENTRAL), (The Cochrane Library Issue 3, 2002), MEDLINE (1980 to 19/11/2002), and EMBASE (1980 to 19/ 11/2002). There was no restriction on language. SELECTION CRITERIA: All randomised controlled trials (RCTs) of participants with permanent anterior teeth suitable for restorations using laminate veneers, comparing direct (different composite materials) and indirect techniques for making dental veneers. The indirect restorations may be
DATA COLLECTION & ANALYSIS: Assessment of relevance and validity and data extraction were conducted in triplicate. Authors of the primary studies were contacted to provide additional information as necessary.
REVIEWERS’ CONCLUSIONS: There is no reliable evidence to show a benefit of one type of veneer restoration (direct or indirect) over the other with regard to the longevity of the restoration. Citation: Wakiaga J, Brunton P, Silikas N, Glenny AM. Direct versus indirect veneer restorations for intrinsic dental stains (Cochrane Review). In: The Cochrane Library, Issue 1, 2004. Chichester, UK: John Wiley & Sons, Ltd.
J Evid Base Dent Pract 2004;2:181-8 D 2004 Mosby, Inc. All rights reserved. doi:10.1016/j.jebdp.2004.04.001
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Abstract
RETENTION PROCEDURES FOR STABILISING TOOTH POSITION AFTER TREATMENT WITH ORTHODONTIC BRACES (Cochrane Review) Littlewood SJ, Millett DT, Doubleday B, Bearn DR, Worthington HV
BACKGROUND: Retention is the phase of orthodontic treatment that attempts to keep teeth in the corrected positions after orthodontic (dental) braces. Without a phase of retention there is a tendency for the teeth to return to their initial position (relapse). To prevent relapse, almost every patient who has orthodontic treatment will require some type of retention. OBJECTIVES: To evaluate the effectiveness of different retention strategies used to stabilize tooth position after orthodontic braces. SEARCH STRATEGY: The Cochrane Oral Health Group’s Trials Register, CENTRAL, MEDLINE and EMBASE were searched. Several journals were handsearched. No language restrictions were applied. Authors of randomised controlled trials (RCTs) were identified and contacted to identify unpublished trials. Most recent search: December 2002. SELECTION CRITERIA: RCTs on children and adults, who have had retainers fitted or adjunctive procedures undertaken, following orthodontic treatment with braces to prevent relapse. The outcomes are: how well the teeth are stabilised, survival of retainers, adverse effects on oral health, and quality of life. DATA COLLECTION & ANALYSIS: Screening of eligible studies, assessment of the methodological quality of the trials and data extraction were conducted in duplicate and independently by 2 reviewers. Because no 2 studies compared the same
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retention strategies (interventions), it was not possible to combine the results of any studies.
MAIN RESULTS: Four trials satisfied the inclusion criteria. These trials all compared different interventions: circumferential supracrestal fiberotomy (CSF) combined with full-time removable retainer versus a full-time removable retainer alone; circumferential supracrestal fiberotomy (CSF) combined with a nights-only removable retainer versus a nights-only removable retainer alone; removable Hawley retainer versus a clear overlay retainer; and 3 types of fixed retainers versus a removable retainer. There was weak unreliable evidence, based on data from 1 trial, that there was a statistically significant increase in stability in both the mandibular (P < 0.001) and maxillary anterior segments (P < 0.001) when the CSF was used, compared with when it was not used. There was also weak, unreliable evidence that teeth settle quicker with a Hawley retainer than with a clear overlay retainer after 3 months. The quality of the trial reports was generally poor. REVIEWERS’ CONCLUSIONS: There are insufficient research data on which to base our clinical practice on retention at present. There is an urgent need for high quality randomised controlled trials in this crucial area of orthodontic practice. Citation: Littlewood SJ, Millett DT, Doubleday B, Bearn DR, Worthington HV. Retention procedures for stabilising tooth position after treatment with orthodontic braces (Cochrane Review). In: The Cochrane Library, Issue 1, 2004. Chichester, UK: John Wiley & Sons, Ltd.
Journal of Evidence-Based Dental Practice June 2004
STABILISATION SPLINT THERAPY FOR TEMPOROMANDIBULAR PAIN DYSFUNCTION SYNDROME (Cochrane Review) Al-Ani MZ, Davies SJ, Gray RJM, Sloan P, Glenny AM BACKGROUND: Pain dysfunction syndrome (PDS) is the most common temporomandibular disorder (TMD). There are many synonyms for this condition including facial arthromyalgia, TMJ dysfunction syndrome, myofascial pain dysfunction syndrome, craniomandibular dysfunction and myofascial pain dysfunction. The aetiology of PDS is multifactorial and many different therapies have been advocated. OBJECTIVES: To establish the effectiveness of stabilisation splint therapy in reducing symptoms in patients with pain dysfunction syndrome. SEARCH STRATEGY: Electronic databases (including the Cochrane Oral Health Group’s Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); The Cochrane Library Issue 2, 2003; MEDLINE (1966 to June 2001); EMBASE (1966 to June 2001)) were searched. Handsearching of relevant journals was undertaken and reference lists of included studies screened. Experts in the field were contacted to identify unpublished articles. There was no language restriction. SELECTION CRITERIA: Randomised or quasi-randomised controlled trials (RCTs), in which splint therapy was compared concurrently to no treatment, other occlusal appliances, or any other active intervention. DATA COLLECTION & ANALYSIS: Data extraction was carried out independently and in duplicate. Validity assessment of the included trials was carried out at the same time as data extraction.
Journal of Evidence-Based Dental Practice Volume 4, Number 2
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Discrepancies were discussed and a third reviewer consulted. The author of the primary study was contacted where necessary. The studies were grouped according to treatment type and duration of follow up.
MAIN RESULTS: Twenty potentially relevant RCTs were identified. Eight trials were excluded, leaving 12 RCTs for analysis. Stabilisation splint therapy was compared to acupuncture, bite plates, biofeedback/stress management, visual feedback, relaxation, jaw exercises, nonoccluding appliance, and minimal/no treatment. There was no evidence of a statistically significant difference in the effectiveness of stabilisation splint therapy in reducing symptoms in patients with pain dysfunction syndrome compared with other active treatments. There is weak evidence to suggest that the use of SS for the treatment of PDS may be beneficial for reducing pain severity, at rest and on palpation, when compared to no treatment. REVIEWERS’ CONCLUSIONS: There is insufficient evidence either for or against the use of stabilisation splint therapy for the treatment of temporomandibular pain dysfunction syndrome. This review suggests the need for further, well conducted RCTs that pay attention to method of allocation, outcome assessment, large sample size, and enough duration of follow up. A standardisation of the outcomes of the treatment of PDS should be established in the RCTs. Citation: Al-Ani MZ, Davies SJ, Gray RJM, Sloan P, Glenny AM. Stabilisation splint therapy for temporomandibular pain dysfunction syndrome (Cochrane Review). In: The Cochrane Library, Issue 1, 2004. Chichester, UK: John Wiley & Sons, Ltd.
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DOMESTIC VIOLENCE SCREENING AND INTERVENTION PROGRAMMES FOR ADULTS WITH DENTAL OF FACIAL INJURY (Cochrane Review) Coulthard P, Yong S, Adamson L, Warburton A, Worthington HV
BACKGROUND: Domestic violence exists in all communities across the world. Health care services have a pivotal role in the identification, assessment, and response to domestic violence. Because the face is a common target in assault, dentists and oral and maxillofacial surgeons are in a unique position to screen for domestic violence in the context of presentation of dental and facial injury. Owing to lack of training, dentists and oral and maxillofacial surgeons may not be the best persons to give advice to someone experiencing domestic violence. Improper advice, such as encouragement to leave an abusive relationship, may escalate the frequency of violence. It may be more appropriate to refer to specialist agencies for intervention and support. It would, therefore be useful to know whether screening and intervention programmes are effective. OBJECTIVES: (1) To assess the benefits and harms of intervention programmes employed to reduce and or prevent domestic violence in adults with dental and/or facial injuries. (2) To assess the benefits and harms of screening and the use of different screening tools in the detection of the proportion of adult victims of domestic violence who present with dental and/ or facial injury.
SEARCH STRATEGY: We searched the Cochrane Oral Health Group’s Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, PsycINFO, and Lilacs databases. No language restrictions were applied. Personal contacts were used and international domestic violence organisations were
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contacted to identify any unpublished trials. Last search was done February 2004.
SELECTION CRITERIA: Randomised controlled trials involving adults aged 16 years and over presenting with dental and/or facial injury relating to domestic violence in any health care setting. DATA COLLECTION & ANALYSIS: Screening of eligible studies was conducted in duplicate and independently by 2 reviewers. Results were to be expressed as random effects models using weighted mean differences for continuous outcomes and relative risk for dichotomous outcomes with 95% confidence interval. Heterogeneity was to be investigated including both clinical and methodological factors. MAIN RESULTS: No eligible randomised controlled trials (RCTs) were identified. REVIEWERS’ CONCLUSIONS: There is no evidence to support or refute that screening for domestic violence in adults with dental or facial injury is beneficial nor that it causes harm. Screening tools to detect domestic violence exist but no RCTs have specifically evaluated their effectiveness for patients presenting with facial and or dental injuries. There is also lack of evidence that intervention programmes are effective at reducing frequency of physical assaults and at reducing the severity of facial injuries. Citation: Coulthard P, Yong S, Adamson L, Warburton A, Worthington HV. Domestic violence screening and intervention programmes for adults with dental of facial injury (Cochrane Review). In: The Cochrane Library, Issue 2, 2004. Chichester, UK: John Wiley & Sons, Ltd.
Journal of Evidence-Based Dental Practice June 2004
PENICILLINS FOR THE PROPHYLAXIS OF BACTERIAL ENDOCARDITIS IN DENTISTRY (Cochrane Review) Oliver R, Roberts GJ, Hooper L BACKGROUND: Many dental procedures cause bacteraemia and it is believed that this may lead to bacterial endocarditis (BE) in a few people. Guidelines in many countries recommend that prior to invasive dental procedures antibiotics are administered to people at high risk of endocarditis. However, it is unclear whether the potential risks of this prophylaxis outweigh the potential benefits. OBJECTIVES: To determine whether prophylactic penicillin administration compared to no such administration or placebo before invasive dental procedures in people at increased risk of BE influences mortality, serious illness, or endocarditis incidence. SEARCH STRATEGY: The search strategy was developed on MEDLINE and adapted for use on the Cochrane Oral Health, Heart and Infectious Diseases Groups’ Trials Registers (to October 2003), as well as the following databases: Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 2, 2002), OLDMEDLINE (1966 to June 2002); EMBASE (1980 to June 2002); SIGLE (to June 2002); and the Meta-register of current controlled trials. SELECTION CRITERIA: Because of the low incidence of BE, it was anticipated that few if any trials would be located. For this reason, cohort and case-controlled studies were included in which suitably matched control or comparison groups had been studied. The intervention was the administration of penicillin compared to no such administration before a dental procedure in people with an increased risk of BE. Cohort studies would need to follow those at increased risk and assess outcomes following any invasive dental procedures, grouping by whether prophylaxis was received. Included casecontrol studies would need to match people who had developed endocarditis (and who were known to be at increased risk before undergoing an invasive dental procedure preceding the onset of endocarditis) with those at similar risk but who had not developed endocarditis. Outcomes of interest included mortality or serious adverse event requiring hospital admission, Journal of Evidence-Based Dental Practice Volume 4, Number 2
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development of endocarditis following any dental procedure in a defined time period, development of endocarditis due to other nondental causes, any recorded adverse events to the antibiotics, and cost implications of the antibiotic provision for the care of those patients who develop endocarditis.
DATA COLLECTION & ANALYSIS: Two reviewers independently selected studies for inclusion, then assessed quality and extracted data from the included study. MAIN RESULTS: No RCTs, CCTs or cohort studies were included. One case-control study met the inclusion criteria. It collected all the cases of endocarditis in the Netherlands over 2 years, finding a total of 24 people who developed endocarditis within 180 days of an invasive dental procedure, definitely requiring prophylaxis according to current guidelines and who were at increased risk of endocarditis due to a pre-existing cardiac problem. This study included participants who died because of the endocarditis (using proxys). Controls attended local cardiology outpatient clinics for similar cardiac problems, had undergone an invasive dental procedure within the past 180 days and were matched by age with the cases. No significant effect of penicillin prophylaxis on the incidence of endocarditis could be seen. No data were found on other outcomes. REVIEWERS’ CONCLUSIONS: There is no evidence about whether penicillin prophylaxis is effective or ineffective against bacterial endocarditis in people at risk who are about to undergo an invasive dental procedure. There is a lack of evidence to support published guidelines in this area. It is not clear whether the potential harms and costs of penicillin administration outweigh any beneficial effect. Ethically practitioners need to discuss the potential benefits and harms of antibiotic prophylaxis with their patients before a decision is made about administration. Citation: Oliver R, Roberts GJ, Hooper L. Penicillins for the prophylaxis of bacterial endocarditis in dentistry (Cochrane Review). In: The Cochrane Library, Issue 2, 2004. Chichester, UK: John Wiley & Sons, Ltd. Cochrane Reviews
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INTERVENTIONS FOR TREATING ORAL MUCOSITIS FOR PATIENTS WITH CANCER RECEIVING TREATMENT (Cochrane Review) Clarkson JE, Worthington HV, Eden OB
Review Updates BACKGROUND: Treatment of cancer is increasingly effective but is associated with short- and long-term side effects. Oral side effects, including oral candidiasis, remain a major source of illness despite the use of a variety of agents to treat them. OBJECTIVES: To assess the effectiveness of interventions for the treatment of oral candidiasis for patients with cancer receiving chemotherapy and/or radiotherapy. SEARCH STRATEGY: Computerised searches of Cochrane Oral Health Group’s Trials Register, CENTRAL, MEDLINE, and EMBASE were undertaken. Reference lists from relevant articles were searched and the authors of eligible trials were contacted to identify trials and obtain additional information. Date of the most recent searches: August 2003: (CENTRAL) (The Cochrane Library Issue 3, 2003). SELECTION CRITERIA: All randomised controlled trials comparing agents prescribed to treat oral candidiasis in people receiving chemotherapy or radiotherapy for cancer. The outcomes were eradication of oral candidiasis, dysphagia, systemic infection, amount of analgesia, length of hospitalisation, cost, and patient quality of life. DATA COLLECTION & ANALYSIS: Data were independently extracted, in duplicate, by 2 reviewers. Authors were contacted for details of randomisation and withdrawals and a quality assessment was carried out. The Cochrane Oral Health Group statistical guidelines were followed and relative risk
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values calculated using random effects models where significant heterogeneity was detected (P < 0.1).
MAIN RESULTS: Eight trials involving 418 patients, satisfied the inclusion criteria and are included in this review. Only 2 agents, each in single trials, were found to be effective for eradicating oral candidiasis. A drug absorbed from the gastrointestinal tract, ketoconazole, was more beneficial than placebo in eradicating oral candidiasis (relative risk [RR] = 0.35, 95% confidence interval (CI): 0.20– 0.61) and clotrimazole, at a higher dose of 50 mg was more effective than a lower 10-mg dose in eradicating oral candidiasis, when assessed mycologically (RR = 0.47, 95% CI: 0.25 –0.89). Another trial demonstrated no statistically significant difference between a 10-mg dose of the partially absorbed drug, clotrimazole, and placebo. No differences were found when comparing different absorbed drugs; and comparing absorbed drugs with drugs that are not absorbed. REVIEWERS’ CONCLUSIONS: There is weak and unreliable evidence that the absorbed drug, ketoconazole, may eradicate oral candidiasis and that a higher dose of the partially absorbed drug, clotrimazole, may give greater benefit than a lower 10-mg dose, however, researchers may wish to prevent rather than treat oral candidiasis. Further welldesigned, placebo-controlled trials assessing the effectiveness of old and new interventions for treating oral candidiasis are needed. Citation: Clarkson JE, Worthington HV, Eden OB. Interventions for treating oral candidiasis for patients with cancer receiving treatment (Cochrane Review). In: The Cochrane Library, Issue 1, 2004. Chichester, UK: John Wiley & Sons, Ltd.
Journal of Evidence-Based Dental Practice June 2004
INTERVENTIONS FOR TREATING ORAL CANDIDIASIS FOR PATIENTS WITH CANCER RECEIVING TREATMENT (Cochrane Review) Clarkson JE, Worthington HV, Eden OB BACKGROUND: Treatment of cancer is increasingly effective but associated with short- and long-term side effects. Oral side effects, including oral mucositis (mouth ulceration), remain a major source of illness despite the use of a variety of agents to treat them. OBJECTIVES: To assess the effectiveness of interventions for treating oral mucositis or its associated pain in patients with cancer receiving chemotherapy and/or radiotherapy. SEARCH STRATEGY: Computerised searches of Cochrane Oral Health Group’s Trials Register, CENTRAL, MEDLINE, and EMBASE were undertaken. Reference lists from relevant articles were searched and the authors of eligible trials were contacted to identify trials and obtain additional information. Date of the most recent searches August 2003: (CENTRAL) (The Cochrane Library Issue 3, 2003). SELECTION CRITERIA: All randomised controlled trials comparing agents prescribed to treat oral mucositis in people receiving chemotherapy and/or radiotherapy. Outcomes were oral mucositis, time to heal mucositis, oral pain, duration of pain control, dysphagia, systemic infection, amount of analgesia, length of hospitalisation, cost, and quality of life. DATA COLLECTION & ANALYSIS: Data were independently extracted, in duplicate, by reviewers. Authors were contacted for details of randomisation, blindness, and withdrawals. Quality assessment was carried out on these 3 criteria. The Cochrane Oral Health Group statistical guidelines were followed and relative risk values calculated using fixed effect models. MAIN RESULTS: Twenty five trials involving 1292 patients satisfied the inclusion criteria. Three agents, each in single trials, were found to be effective for improving (allopurinol
Journal of Evidence-Based Dental Practice Volume 4, Number 2
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RR 3.33, 95% CI: 1.06 –10.49; immunoglobulin RR 1.81, 95% CI: 1.24 –2.65; human placental extract RR 4.50, 95% CI: 2.29 –8.86) or eradicating mucositis (allopurinol RR 19.00, 95% CI: 1.17 –307.63). Two of these trials were rated as at moderate risk of bias and one as at high risk of bias. The following agents were not found to be effective: benzydamine HCl, sucralfate, tetrachlorodecaoxide, chlorhexidine, and ‘‘magic’’ (lidocaine solution, diphenhydramine hydrochloride, and aluminum hydroxide suspension). Six trials compared the time to heal and mucositis was found to heal more quickly with 2 interventions: granulocyte macrophage-colony stimulating factor when compared with povidone iodine, with mean difference 3.5 days (95% CI: 4.1 to 2.9) and allopurinol compared to placebo, with mean difference 4.5 days (95% CI: 5.8 to 3.2). Three trials compared patient controlled analgesia (PCA) to the continuous infusion method for controlling pain. There was no evidence of a difference, however, less opiate was used per hour for PCA, and the duration of pain was shorter. One trial demonstrated that pharmacokinetically based analgesia (PKPCA) reduced pain compared with PCA, however, more opiate was used with PKPCA.
REVIEWERS’ CONCLUSIONS: There is weak and unreliable evidence that allopurinol mouthwash, vitamin E, immunoglobulin, or human placental extract improve or eradicate mucositis. There is no evidence that patient-controlled analgesia (PCA) is better than continuous infusion method for controlling pain, however, less opiate was used per hour, and duration of pain was shorter, for PCA. Further, welldesigned, placebo-controlled trials assessing the effectiveness of allopurinol mouthwash, immunoglobulin, human placental extract, other interventions investigated in this review and new interventions for treating mucositis are needed. Citation: Clarkson JE, Worthington HV, Eden OB. Interventions for treating oral mucositis for patients with cancer receiving treatment (Cochrane Review). In: The Cochrane Library, Issue 2, 2004. Chichester, UK: John Wiley & Sons, Ltd.
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Cochrane News 12TH ANNUAL COCHRANE COLLOQUIUM: (2ND –6TH OCTOBER 2004, OTTAWA, CANADA) The 12th annual Cochrane Colloquium will take place in Ottawa, Canada from 2nd to 6th October 2004. The theme is ‘Bridging the Gaps’ i.e., the gaps between the Cochrane Collaboration and clinical practice, gaps between high and low-income countries and individuals, gaps between methodologists and reviewers, and gaps between producers and users of health care information. The scientific program of plenary sessions, workshops, papers and posters will address many of these gaps and offer helpful solutions. The target audience includes: 1. Current contributors to The Cochrane Collaboration, both newcomers and experienced members. 2. People with an interest in learning more about the organisation and its activities. 3. Potential partner organisations and institutions. 4. Health care policy makers, clinicians and consumers interested in the application of Cochrane systematic reviews to health policies, patient care, and personal decision-making.
EVIDENCE BASED PRACTICE IN DENTISTRY COURSE(7th –9th June 2004, Manchester, UK): A 3-day course for all dentists and members of the dental team is organised annually by the editorial team of the Cochrane Oral Health Group in Manchester, UK. The aim of the course is to provide the skills to implement an evidence-based care approach for effective clinical practice, audit, and research. The 3 days of workshops are complemented by distance learning, self-directed study, and mentored support, and at the end of the course the participants will be able to: 1. Understand the ideas and principles of evidencebased practice. 2. Identify clinical issues where assessment of the evidence would be helpful. 3. Search out and critically appraise relevant dental literature. 4. Concisely present the evidence on a clinical issue. 5. Interpret their findings and develop an implementation strategy, audit criteria, and/or research plan. The next course is to be held in June (7th –9th) 2004 and for further information visit www.cochrane-oral. man.ac.uk of contact [email protected]
The Cochrane Oral Health Group will be holding a meeting during the colloquium and cordially invites all those interested in learning more about the group and the Cochrane Collaboration. For further information visit: www.cochrane.org
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Journal of Evidence-Based Dental Practice June 2004