practice worksheet C

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Practice Worksheet C: Identifying the Evidence

There are five abstracts in this file (scroll down to see them). The abstracts contain enough information for you to decide what the study design is.

· (2.5 POINTS, 0.5 POINT for each abstract) For each abstract, choose the study design by checking the correct box in the table.

· (2.5 POINTS, 0.5 POINT for each abstract) Rank the abstracts from the HIGHEST level of evidence to the LOWEST level of evidence

Abstract #	1	2	3	4	5
Meta analysis
Systematic review
Randomized controlled trial
Cohort study
Case control study
Case series
Case report
Idea, editorial, opinion
Animal research
In vitro research

Rank the study designs of the abstracts from highest level of evidence to lowest:

ABSTRACT #1

Am J Orthod Dentofacial Orthop. 2010 Sep;138(3):285-91.

Modified fluoride toothpaste technique reduces caries in orthodontic patients: A longitudinal, randomized clinical trial.

Al Mulla AH, Kharsa SA, Birkhed D.

Departments of Cariology and Orthodontics, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden. [email protected]

Abstract

INTRODUCTION: The hypothesis of this study was that toothpaste slurry rinsing, combined with other simple postbrushing steps (the modified fluoride toothpaste technique [MFTT]), would reduce the number of decayed and filled tooth surfaces.

METHODS: The study population consisted of 100 orthodontic patients randomly divided into 2 groups, 51 in the test group (mean age, 16.2 +/- 4 years) and 49 in the control group (mean age, 16.9 +/- 4 years). Each patient was examined before starting orthodontic treatment (baseline) and shortly after debonding (follow-up) in a 2-year study period. At each of these 2 visits, the patients were examined in the following order: interviewed by using a standardized questionnaire, plaque index registration, intraoral clinical examination, and radiographic examination (bitewings). The test group patients were instructed to use the MFTT. The control group patients were given the same fluoridated toothpaste as the test group and the routine clinical oral hygiene instructions.

RESULTS: Compared with the control group, the test group had significantly better plaque index scores at the end of the study. At follow-up, the clinical (P <0.001), radiographic (P <0.001), and clinical plus radiographic (P <0.001) incidences of decayed and filled surfaces were significantly reduced: 87%, 78%, and 83%, respectively, in the test group compared with the control group.

CONCLUSIONS: Compared with routine oral hygiene instructions with fluoride toothpaste, the use of the MFTT significantly reduced the incidence of new carious lesions in orthodontic patients. We believe that this simple regimen should be considered in orthodontic clinics.

ABSTRACT #2

J Periodontol. 2010 Jul;81(7):992-1000.

Periodontitis: a future risk of acute coronary syndrome? A follow-up study over 3 years.

Renvert S, Ohlsson O, Pettersson T, Persson GR.

Department of Health Sciences, University of Kristianstad, Kristianstad, Sweden.

Abstract

BACKGROUND: Periodontitis has been associated with cardiovascular disease. We assess if the recurrence of acute coronary syndrome (ACS) could be predicted by preceding medical and periodontal conditions.

METHODS: A total of 165 consecutive subjects with ACS and 159 medically healthy, matched control subjects were examined and followed for 3 years. Periodontitis was defined by alveolar bone loss. Subgingival microbial samples were studied by the checkerboard DNA-DNA hybridization method.

RESULTS: The recurrence of ACS was found in 66 of 165 (40.0%) subjects, and a first ACS event was found in seven of 159 (4.4%) subjects among baseline control subjects. Subjects who later had a second ACS event were older (P <0.001). Significantly higher serum levels of high-density lipoprotein (P <0.05), creatinine (P <0.01), and white blood cell (WBC) counts (P <0.001) were found in subjects with future ACS. Periodontitis was associated with a first event of ACS (crude odds ratio [OR]: 10.3:1; 95% confidence interval [CI]: 6.1 to 17.4; P <0.001) and the recurrence of ACS (crude OR: 3.6:1; 95% CI: 2.0 to 6.6; P <0.001). General linear modeling multivariate analysis, controlling for age and the prediction of a future ACS event, identified that WBC counts (F = 20.6; P <0.001), periodontitis (F = 17.6; P <0.001), and serum creatinine counts (F = 4.5; P <0.05) were explanatory of a future ACS event.

CONCLUSIONS: The results of this study indicate that recurrent ACS events are predicted by serum WBC counts, serum creatinine levels, and a diagnosis of periodontitis. Significantly higher counts of putative pathogens are found in subjects with ACS, but these counts do not predict future ACS events.

ABSTRACT #3

J Periodontol. 2010 Jun;81(6):945-52.

Double flap incision design for guided bone regeneration: a novel technique and clinical considerations.

Hur Y, Tsukiyama T, Yoon TH, Griffin T.

Department of Periodontology, Tufts University School of Dental Medicine, Boston, MA 02111, USA. [email protected]

Abstract

BACKGROUND: Premature membrane exposure for guided bone regeneration may result in complications, such as inadequate bone regeneration, inflammatory reactions, and wound infection. This paper presents a clinical case of a novel incision-flap design used to advance the flap to enhance tension-free primary closure for the vertical ridge augmentation.

METHODS: A 61-year-old white man presented with the chief complaint of wanting to replace his posterior mandibular teeth. A severe alveolar bone deformity vertically and horizontally (Seibert Class III) was noticed, especially over the mental foramen area. A staged guided bone regeneration procedure prior to the implant installation was chosen as the most optimal treatment. A partial-thickness flap, separating the mucosal flap from the periosteum overlying the alveolar bone, was used to advance the flap.

RESULTS: During the healing period, neither soft tissue dehiscence nor membrane exposure were noted. Clinical and radiographic evaluation revealed a 4- to 5-mm gain in vertical height and a noticeable increase in horizontal thickness. After the 6 to 8 months of healing for both sites, two implants were placed on each side with good primary stability and without complications.

CONCLUSIONS: This technique facilitates flap advancement by the tension-free nature of the design and enhances soft tissue maintenance during the course of regeneration. This approach, the separation of the periosteal layer and the mucosal layer, can be used as an alternative to overcome some of the limitations with conventional technique.

ABSTRACT #4

Aust Dent J. 2010 Sep;55(3):351-2.

Replacement versus repair of defective restorations in adults: resin composite.

Sharif MO, Catleugh M, Merry A, Tickle M, Dunne SM, Brunton P, Aggarwal VR.

Abstract

BACKGROUND: Composite filling materials have been increasingly used for the restoration of posterior teeth in recent years as a tooth coloured alternative to amalgam. As with any filling material composites have a finite life-span. Traditionally, replacement was the ideal approach to treat defective composite restorations, however, repairing composites offers an alternative more conservative approach where restorations are partly still serviceable. Repairing the restoration has the potential of taking less time and may sometimes be performed without the use of local anaesthesia hence it may be less distressing for a patient when compared with replacement.

OBJECTIVES: To evaluate the effectiveness of replacement (with resin composite) versus repair (with resin composite) in the management of defective resin composite dental restorations in permanent molar and premolar teeth.

SEARCH STRATEGY: For the identification of studies relevant to this review we searched the Cochrane Oral Health Group Trials Register (to 23rd September 2009); CENTRAL (The Cochrane Library 2009, Issue 4); MEDLINE (1950 to 23rd September 2009); EMBASE (1980 to 23rd September 2009); ISI Web of Science (SCIE, SSCI) (1981 to 22nd December 2009); ISI Web of Science Conference Proceedings (1990 to 22nd December 2009); BIOSIS (1985 to 22nd December 2009); and OpenSIGLE (1980 to 2005). Researchers, experts and organizations known to be involved in this field were contacted in order to trace unpublished or ongoing studies. There were no language limitations.

SELECTION CRITERIA: Trials were selected if they met the following criteria: randomized or quasi-randomized controlled trial, involving replacement and repair of resin composite restorations.

DATA COLLECTION AND ANALYSIS: Two review authors independently assessed titles and abstracts for each article identified by the searches in order to decide whether the article was likely to be relevant. Full papers were obtained for relevant articles and both review authors studied these. The Cochrane Collaboration statistical guidelines were to be followed for data synthesis.

MAIN RESULTS: The search strategy retrieved 279 potentially eligible studies, after de-duplication and examination of the titles and abstracts all but four studies were deemed irrelevant. After further analysis of the full texts of the four studies identified, none of the retrieved studies met the inclusion criteria and all were excluded from this review.

AUTHORS' CONCLUSIONS: There are no published randomised controlled clinical trials relevant to this review question. There is therefore a need for methodologically sound randomised controlled clinical trials that are reported according to the Consolidated Standards of Reporting Trials (CONSORT) statement (http://www.consort-statement.org/). Further research also needs to explore qualitatively the views of patients on repairing versus replacement and investigate themes around pain, anxiety and distress, time and costs.

ABSTRACT #5

J Periodontol. 2010 Sep 1. [Epub ahead of print]

Vitamin D Status and Periodontal Disease Among Pregnant Women.

Boggess KA, Espinola JA, Moss K, Beck J, Offenbacher S, Camargo CA.

Departments of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC.

Abstract

Background: Maternal periodontal disease is found in up to 40% of pregnant women and is associated with adverse pregnancy outcomes. Vitamin D deficiency may play a role in periodontal disease and tooth loss, and insufficient vitamin D status is common among pregnant women. The objective of this study was to examine the relationship between maternal vitamin D status and periodontal disease. Methods: A case-control study was conducted. Cases were defined as pregnant women with clinical moderate/severe periodontal disease; controls were pregnant women who were periodontally healthy. Maternal data was chart abstracted and serum was collected between 14-26 weeks' gestation. Serum 25-hydroxyvitamin D (25[OH]D) levels were measured using liquid chromatography - tandem mass spectrometry. Median serum 25(OH)D levels and prevalence of vitamin D insufficiency (defined as <75 nmol/L) were compared between cases and controls. The odds ratio (OR) and 95% confidence interval(CI) for moderate/severe periodontal disease among women with vitamin D insufficiency was calculated using multivariable logistic regression, adjusting for maternal race, season of blood draw and other potential confounders. Results: 117 cases were compared to 118 controls. Cases had lower median 25(OH)D levels than controls (59 vs. 100 nmol/L, P<.001) and were more likely to have vitamin D insufficiency (65% vs. 29%, P<.001). The adjusted OR (95%CI) for moderate/severe periodontal disease among women with vitamin D insufficiency was 2.2 (.99-4.5). Conclusion: Vitamin D insufficiency (serum 25(OH)D < 75 nmol/L) is associated with maternal periodontal disease during pregnancy. Vitamin D supplementation represents a potential therapeutic strategy to improve maternal oral health.