Glick M, Urquhart O, Bhosale AS, Carrasco-Labra A, Edelson JT. A unified voice to drive global improvements in oral health. BMC Global and Public Health 2023;1(1):19.
Approximately, 3.47 billion individuals worldwide are affected by oral disorders, with untreated dental caries being the most prevalent issue, impacting 2.30 billion people. Addressing this complex health problem requires a collective and unified approach from the oral health community. However, stakeholders often focus on their own interests, leading to information silos and a lack of diverse perspectives. To foster collaboration, tackle critical topics, and promote effective communication, the Global Oral Health Forum was organized as a 2-day meeting. The forum aimed to dismantle existing silos and cultivate a unified message to drive global improvements in oral health. By bridging gaps between stakeholders and encouraging dialogue, the forum sought to transcend individual interests and foster a holistic approach. The meeting provided a space for diverse viewpoints, concerns, and expertise to converge, facilitating meaningful discussions and overcoming the limitations of an echo chamber. The inclusive environment aimed to integrate different perspectives, generate innovative ideas, and pave the way for impactful changes in oral health worldwide. The outcome of the Global Oral Health Forum I includes suggested action points that emphasize collaboration, knowledge sharing, and policy development. These recommendations aim to promote preventive strategies, improve access to oral healthcare, enhance oral health education, and foster interdisciplinary research and innovation. By implementing these actions, the global oral health community can work together to address the challenges posed by oral disorders and improve oral health outcomes for billions of individuals worldwide.
Listl S, Baltussen R, Carrasco-Labra A, Carrer FC, Lavis JN. Evidence-Informed Oral Health Policy Making: Opportunities and Challenges. Journal of Dental Research. 2023;0(0).
Despite a clear need for improvement in oral health systems, progress in oral health systems transformation has been slow. Substantial gaps persist in leveraging evidence and stakeholder values for collective problem solving. To truly enable evidence-informed oral health policy making, substantial “know-how” and “know-do” gaps still need to be overcome. However, there is a unique opportunity for the oral health community to learn and evolve from previous successes and failures in evidence-informed health policy making. As stated by the Global Commission on Evidence to Address Societal Challenges, COVID-19 has created a once-in-a-generation focus on evidence, which has fast-tracked collaboration among decision makers, researchers, and evidence intermediaries. In addition, this has led to a growing recognition of the need to formalize and strengthen evidence-support systems. This article provides an overview of recent advancements in evidence-informed health policy making, including normative goals and a health systems taxonomy, the role of evidence-support and evidence-implementation systems to improve context-specific decision-making processes, the evolution of learning health systems, and the important role of citizen deliberations. The article also highlights opportunities for evidence-informed policy making to drive change in oral health systems. All in all, strengthening capacities for evidence-informed health policy making is critical to enable and enact improvements in oral health systems.
Keywords: Citizen science; decision making; evidence-based dentistry; stakeholder participation.
Dhar V, Pilcher L, Fontana M, González-Cabezas C, Keels MA, Mascarenhas AK, Nascimento M, Platt JA, Sabino GJ, Slayton R, Tinanoff N, Young DA, Zero DT, Pahlke S, Urquhart O, O’Brien KK, Carrasco-Labra A. Evidence-based clinical practice guideline on restorative treatments for caries lesions: A report from the American Dental Association. J Am Dent Assoc. 2023 Jul;154(7):551-566.e51.
Background: An expert panel convened by the American Dental Association (ADA) Council on Scientific Affairs together with the ADA Science and Research Institute’s program for Clinical and Translational Research conducted a systematic review and developed recommendations for the treatment of moderate and advanced cavitated caries lesions in patients with vital, nonendodontically treated primary and permanent teeth.
Types of studies reviewed: The authors searched for systematic reviews comparing carious tissue removal (CTR) approaches in Ovid MEDLINE, Embase, Cochrane Database of Systematic Reviews, and Trip Medical Database. The authors also conducted a systematic search for randomized controlled trials comparing direct restorative materials in Ovid MEDLINE, Embase, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform. The authors used the Grading of Recommendations Assessment, Development, and Evaluation approach to assess the certainty of the evidence and formulate recommendations.
Results: The panel formulated 16 recommendations and good practice statements: 4 on CTR approaches specific to lesion depth and 12 on direct restorative materials specific to tooth location and surfaces involved. The panel conditionally recommended for the use of conservative CTR approaches, especially for advanced lesions. Although the panel conditionally recommended for the use of all direct restorative materials, they prioritized some materials over the use of others for certain clinical scenarios.
Practical implications: The evidence suggests that more conservative CTR approaches may decrease the risk of adverse effects. All included direct restorative materials may be effective in treating moderate and advanced caries lesions on vital, nonendodontically treated primary and permanent teeth.
Keywords: American Dental Association; Evidence-based dentistry; caries; clinical practice guideline; direct restorative materials; general dentistry; pediatric dentistry.
Abt E, Weyant RJ, Frantsve-Hawley J, Carrasco-Labra A. The potential harm of not following clinical practice guideline recommendations. J Am Dent Assoc. 2023 Aug;154(8):760-765.
Background: Clinical practice guidelines (CPGs) provide recommendations for clinicians on the basis of best evidence. CPGs are often not followed because of numerous barriers, including lack of awareness, inability to understand recommendations, and problems with implementation.
Case description: A case report is presented in which treatment of a patient’s incipient caries lesions may not have followed a CPG available to practitioners, recommending conservative nonrestorative medical interventions. The resulting treatment led to pain and the need for endodontic therapy and full-coverage restoration.
Practical implications: This case represents possible mismanagement leading to undue pain and additional costs that could have been avoided by being aware of, and following, the recommendations from CPGs.
Keywords: Clinical practice guidelines; evidence-based dentistry; operative dentistry.
Wang Y, Devji T, Carrasco-Labra A, Qasim A, Hao Q, Kum E, Devasenapathy N, King MT, Terluin B, Terwee CB, Walsh M, Furukawa TA, Tsujimoto Y, Guyatt GH. An extension minimal important difference credibility item addressing construct proximity is a reliable alternative to the correlation item. J Clin Epidemiol. 2023 May;157:46-52.
Objectives: Minimal important difference (MID), the smallest change or difference that patients perceive as important, aids interpretation of change in patient-reported outcome measure (PROM) scores. A credibility instrument that assesses the methodological rigor of an anchor-based MID includes one core item addressing the correlation between the PROM and the anchor. However, the majority of MID studies in literature fail to report the correlation. To address this issue, we extended the anchor-based MID credibility instrument by adding an item addressing construct proximity as an alternative to the correlation item.
Study Design and Setting: Informed by an MID methodological survey, we added an alternative item—a subjective assessment of similarity of the constructs (i.e., construct proximity) between PROM and anchor—to the correlation item and generated principles for the assessment. We sampled 101 MIDs and analyzed the assessments performed by each pair of raters. By calculating weighted Cohen’s kappa, we assessed the reliability of the assessments.
Results: Construct proximity assessment is based on the anticipated association between the anchor and PROM constructs: the closer the anticipated association, the higher the rating. Our detailed principles address the most frequently used anchors: transition ratings, measures of satisfaction, other PROMs, and clinical measures. The assessments showed acceptable agreement (weighted kappa 0.74, 95% CI 0.55–0.94) between raters.
Conclusion: In the absence of a reported correlation coefficient, construct proximity assessment provides a useful alternative in the credibility assessment of anchor-based MID estimates.
Wang Y, Devji T, Carrasco-Labra A, King MT, Terluin B, Terwee CB, Walsh M, Furukawa TA, Guyatt GH. A step-by-step approach for selecting an optimal minimal important difference. BMJ. 2023 May 26;381:e073822.
Researchers have proposed that the minimal important difference (MID), the smallest change or difference that patients perceive as important, could aid the interpretation of patient reported outcomes measure (PROM) scores. When multiple MIDs for a given PROM differ substantially, the selection of an optimal MID to aid interpretation could prove challenging. This article describes a systematic, step-by-step selection approach developed to resolve this problem. An optimal MID, at least, should be methodologically sound and should, as far as possible, match the intended application contexts. Therefore, this approach is geared to explaining the variability of the MIDs for the PROM of interest by the methodological rigor and contextualized factors influencing the MID application, and where appropriate, provides one optimal MID (i.e., the median of the selected estimates in a relatively narrow range).
Miroshnychenko A, Azab M, Ibrahim S, Roldan Y, Diaz Martinez JP, Tamilselvan D, He L, Urquhart O, Tampi M, Polk DE, Moore PA, Hersh EV, Carrasco-Labra A, Brignardello-Petersen R. Analgesics for the management of acute dental pain in the pediatric population: A systematic review and meta-analysis. J Am Dent Assoc. 2023 May;154(5):403-416.e14.
Background: The authors assessed the clinical effectiveness of analgesics to manage acute pain after dental extractions and pain associated with irreversible pulpitis in children.
Types of Studies Reviewed: The authors searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and US Clinical Trials registry from inception through November 2020. They included randomized controlled trials comparing any pharmacologic interventions with each other and a placebo in pediatric participants undergoing dental extractions or experiencing irreversible pulpitis. After duplicate screening and data abstraction, the authors conducted random-effects meta-analyses. They assessed risk of bias using the Cochrane Risk of Bias 2.0 tool and certainty of the evidence using the Grading of Recommendations Assessment, Development and Evaluation approach.
Results: The authors included 6 randomized controlled trials reporting 8 comparisons. Ibuprofen may reduce pain intensity compared with acetaminophen (mean difference [MD], 0.27 points; 95% CI, -0.13 to 0.68; low certainty) and a placebo (MD, -0.19 points; 95% CI, -0.58 to 0.21; low certainty). Acetaminophen may reduce pain intensity compared with a placebo (MD, -0.13 points; 95% CI, -0.52 to 0.26; low certainty). Acetaminophen and ibuprofen combined probably reduce pain intensity compared with acetaminophen alone (MD, -0.75 points; 95% CI, -1.22 to -0.27; moderate certainty) and ibuprofen alone (MD, -0.01 points; 95% CI, -0.53 to 0.51; moderate certainty). There was very low certainty evidence regarding adverse effects.
Practical Implications: Several pharmacologic interventions alone or in combination may provide a beneficial effect when managing acute dental pain in children. There is a paucity of evidence regarding the use of analgesics to manage irreversible pulpitis.
Key Words: Acute dental pain; dental extraction; toothache; irreversible pulpitis; systematic review; nonsteroidal antiinflammatory; acetaminophen.
Miroshnychenko, A., Ibrahim, S., Azab, M., Roldan, Y., Martinez, J. P. D., Tamilselvan, D., He, L., Little, J. W., Urquhart, O., Tampi, M., Polk, D. E., Moore, P. A., Hersh, E. V., Claytor, B., Carrasco-Labra, A., & Brignardello-Petersen, R. (2023). Acute Postoperative Pain Due to Dental Extraction in the Adult Population: A Systematic Review and Network Meta-analysis. J Dent Res, 220345221139230.
This study compares the effectiveness of pharmacological treatments to develop guidelines for the management of acute pain after tooth extraction. We searched Medline, EMBASE, CENTRAL, and US Clinical Trials registry on November 21, 2020. We included randomized clinical trials (RCTs) of participants undergoing dental extractions comparing 10 interventions, including acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, and combinations to placebo. After duplicate screening and data abstraction, we conducted a frequentist network meta-analysis for each outcome at 6 h (i.e., pain relief, total pain relief [TOTPAR], summed pain intensity difference [SPID], global efficacy rating, rescue analgesia, and adverse effects). We assessed the risk of bias using a modified Cochrane RoB 2.0 tool and the certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation approach. We implemented the analyses in RStudio version 3.5.3 and classified interventions from most to least beneficial or harmful. We included 82 RCTs. Fifty-six RCTs enrolling 9,095 participants found moderate- and high-certainty evidence that ibuprofen 200 to 400 mg plus acetaminophen 500 to 1,000 mg (mean difference compared to placebo [MDp], 1.68; 95% confidence interval [CI], 1.06–2.31), acetaminophen 650 mg plus oxycodone 10 mg (MDp, 1.19; 95% CI, 0.85–1.54), ibuprofen 400 mg (MDp, 1.31; 95% CI, 1.17–1.45), and naproxen 400–440 mg (MDp, 1.44; 95% CI, 1.07–1.80) were most effective for pain relief on a 0 to 4 scale. Oxycodone 5 mg, codeine 60 mg, and tramadol 37.5 mg plus acetaminophen 325 mg were no better than placebo. The results for TOTPAR, SPID, global efficacy rating, and rescue analgesia were similar. Based on low- and very low-certainty evidence, most interventions were classified as no more harmful than placebo for most adverse effects. Based on moderate- and high-certainty evidence, NSAIDs with or without acetaminophen result in better pain-related outcomes than opioids with or without acetaminophen (except acetaminophen 650 mg plus oxycodone 10 mg) or placebo.
Verdugo-Paiva, F., Bonfill, X., Ortuno, D., Glick, M., & Carrasco-Labra, A. (2023). Policymakers’ Perceived Barriers and Facilitators in the Use Of Research Evidence in Oral Health Policies and Guidelines: A Qualitative Study Protocol. BMJ Open, 13(2), e066048.
Evidence-informed oral health policies are crucial to improving patient and population outcomes, but policymakers and organisational leaders infrequently systematically incorporate research evidence. Although there is indirect evidence regarding challenges in other healthcare sectors, the use of evidence-informed oral health policies remains unstudied in oral health. This study aims to assess policymakers’ perceived needs, barriers and facilitators in using research evidence to inform policies in oral health.
Fisher, J., R. Berman, K. Buse, B. Doll. M. Glick, J. Metzl, and R. Touger-Decker. 2023. “Achieving Oral Health for All through Public Health Approaches, Interprofessional, and Transdisciplinary Education. “NAM Perspectives. Discussion Paper, National Academy of Medicine, Washington, DC.
This paper aims to use newly expanded definitions of oral health—from the World Health Organization and the FDI World Dental Federation (FDI) (Glick et al., 2016)—to describe opportunities for engaging policy- and decision-makers in ministries, departments of health, and other agencies around the concept of holistic oral health (i.e., mind, mouth, body, soul, and spirit) as it relates to the UN 2030 Agenda for Sustainable Development.
Pilcher, L., Pahlke, S., Urquhart, O., O’Brien, K. K., & Carrasco-Labra, A. (2023). Plain language summary for “Direct materials for restoring caries lesions: systematic review and meta-analysis-a report of the American Dental Association Council on Scientific Affairs”. J Am Dent Assoc. online ahead of print.
The American Dental Association’s Council on Scientific Affairs and the American Dental Association Science and Research Institute’s Clinical and Translational Research program convened a panel of subject matter experts to develop a clinical practice guideline on restorative treatments for caries lesions. The upcoming guideline will present recommendations for direct restorative materials and carious tissue removal approaches for cavitated caries lesions on primary and permanent teeth. This systematic review and meta-analysis presents the evidence informing the effectiveness of different direct restorative materials and the certainty of the evidence.
Pilcher, L., Pahlke, S., Urquhart, O., O’Brien, K. K., Dhar, V., Fontana, M., Gonzalez-Cabezas, C., Keels, M. A., Mascarenhas, A. K., Nascimento, M. M., Platt, J. A., Sabino, G. J., Slayton, R. L., Tinanoff, N., Young, D. A., Zero, D. T., Tampi, M. P., Purnell, D., Salazar, J., . . . Carrasco-Labra, A. (2023). Direct materials for restoring caries lesions: Systematic review and meta-analysis-a report of the American Dental Association Council on Scientific Affairs. J Am Dent Assoc. online ahead of print.
Background: The goal of restoring caries lesions is to protect the pulp, prevent progression of the disease process, and restore the form and function of the tooth. The purpose of this systematic review was to determine the effect of different direct restorative materials for treating cavitated caries lesions on anterior and posterior primary and permanent teeth.
Type of studies reviewed: The authors included parallel and split-mouth randomized controlled trials comparing the effectiveness of direct restorative materials commercially available in the United States placed in vital, nonendodontically treated primary and permanent teeth. Pairs of reviewers independently conducted study selection, data extraction, and assessments of risk of bias and certainty of the evidence using the Grading of Recommendations Assessment, Development and Evaluation approach. The authors conducted pair-wise meta-analyses to summarize the evidence and calculated measures of association and their 95% CIs.
Results: Thirty-eight randomized controlled trials were eligible for analysis, which included data on Class I and Class II restorations on primary teeth and Class I, Class II, Class III, Class V, and root surface restorations on permanent teeth. Included studies assessed the effect of amalgam, resin composite, compomer, conventional glass ionomer cement, resin-modified glass isomer cement, and preformed metal crowns. Moderate to very low certainty evidence suggested varying levels of effectiveness across restorative materials.
Conclusions and practical implications: Owing to a relatively low event rate across various outcomes indicating restoration failure, there was limited evidence to support important differences between direct restorative materials used in practice.
Keywords: American Dental Association; Evidence-based dentistry; dental caries; direct restorative materials; general dentistry; meta-analysis; pediatric dentistry; systematic review.
Miroshnychenko, A., Ibrahim, S., Azab, M., Roldan, Y., Diaz Martinez, J. P., Tamilselvan, D., He, L., Urquhart, O., Tampi, M., Polk, D. E., Moore, P. A., Hersh, E. V., Carrasco-Labra, A., & Brignardello-Petersen, R. (2023). Injectable and topical local anesthetics for acute dental pain: 2 systematic reviews. J Am Dent Assoc, 154(1), 53-64 e14.
Background: Local anesthesia is essential for pain control in dentistry. The authors assessed the comparative effect of local anesthetics on acute dental pain after tooth extraction and in patients with symptomatic irreversible pulpitis.
Types of studies reviewed: The authors searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and the US Clinical Trials registry through November 21, 2020. The authors included randomized controlled trials (RCTs) comparing long- vs short-acting injectable anesthetics to reduce pain after tooth extraction (systematic review 1) and evaluated the effect of topical anesthetics in patients with symptomatic pulpitis (systematic review 2). Pairs of reviewers screened articles, abstracted data, and assessed risk of bias using a modified version of the Cochrane risk of bias 2.0 tool. The authors assessed the certainty of the evidence using the Grading of Recommendations Assessment, Development and Evaluation approach.
Results: Fourteen RCTs comparing long- vs short-acting local anesthetics suggest that bupivacaine may decrease the use of rescue analgesia and may not result in additional adverse effects (low certainty evidence). Bupivacaine probably reduces the amount of analgesic consumption compared with lidocaine with epinephrine (mean difference, -1.91 doses; 95% CI, -3.35 to -0.46; moderate certainty) and mepivacaine (mean difference, -1.58 doses; 95% CI, -2.21 to -0.95; moderate certainty). Five RCTs suggest that both benzocaine 10% and 20% may increase the number of people experiencing pain reduction compared with placebo when managing acute irreversible pulpitis (low certainty).
Practical implications: Bupivacaine may be superior to lidocaine with epinephrine and mepivacaine with regard to time to and amount of analgesic consumption. Benzocaine may be superior to placebo in reducing pain for 20 through 30 minutes after application.
Keywords: Short-acting local anesthetics; articaine; benzocaine; bupivacaine; lidocaine; long-acting local anesthetics; mepivacaine; post tooth extraction acute pain; symptomatic irreversible pulpitis.
Baker, D., Giuliano, K. K., Thakkar-Samtani, M., Scannapieco, F. A., Glick, M., Restrepo, M. I., Heaton, L. J., & Frantsve-Hawley, J. (2022). The association between accessing dental services and nonventilator hospital-acquired pneumonia among 2019 Medicaid beneficiaries.
In this 2019 cross-sectional study, we analyzed hospital records for Medicaid beneficiaries who acquired nonventilator hospital-acquired pneumonia. The results suggest that preventive dental treatment in the 12 months prior or periodontal therapy in the 6 months prior to a hospitalization is associated with a reduced risk of NVHAP.
Giuliano, K. K., Baker, D., Thakkar-Samtani, M., Glick, M., Restrepo, M. I., Scannapieco, F. A., Heaton, L. J., & Frantsve-Hawley, J. (2022). Incidence, mortality, and cost trends in nonventilator hospital-acquired pneumonia in medicaid beneficiaries, 2015-2019. Am J Infect Control.
Nonventilator hospital-acquired pneumonia is associated with substantial morbidity, mortality, and costs during an episode of acute care. We examined NVHAP incidence, mortality, and costs of Medicaid beneficiaries over a 5-year period (2015-2019). Overall NVHAP incidence was 2.63 per 1,000 patient days, and mortality was 7.76%, with an excess cost per NVHAP case of $20,189.
Ahmad, P., Hussain, A., Carrasco-Labra, A., & Siqueira, W. L. (2022). Salivary Proteins as Dental Caries Biomarkers: A Systematic Review. Caries Res, 56(4), 385-398.
Salivary proteins play an important role in repairing mechanisms of damaged tissues and the maintenance of oral health. However, there is a dearth of information in the literature regarding the concentrations of salivary proteins in caries-free (CF) and caries-active (CA) subjects. Hence, this systematic review was conducted to update our previous systematic review published in 2013 that aimed to assess the association between caries and salivary proteins by comparing CF and CA individuals. Thereby, evaluating the possibility of whether salivary proteins can be regarded as biomarkers for caries. An extensive search of studies was conducted using PubMed, EMBASE, Clarivate Analytics’ Web of Science, and Elsevier’s Scopus between July 2012 and January 2022, without any language restriction. Manual searching in Google Scholar and evaluation of bibliographies of the included studies were also undertaken. The Newcastle-Ottawa Scale was used to assess the risk of bias (RoB) within the included studies. Of 22 included studies, 1,551 human subjects (range: 30-213 participants) were recruited, of which 848 individuals (54.7%) were CA and 703 (45.3%) were CF. Regarding the utilization of DMFT as the caries index, high variability was observed across different articles. A statistically significant increase in the salivary levels of alpha-amylase, acidic proline-rich protein-1, histatin-5, lactoperoxidase, and mucin-1 was found in CA patients, while the salivary levels of carbonic anhydrase 6, proteinase-3, and statherin were observed to be significantly increased in CF subjects. Conflicting results were found regarding the salivary levels of immunoglobulin A and total proteins among CA and CF subjects. The included studies were categorized as low RoB (n = 15), medium RoB (n = 4), and high RoB (n = 3). Due to significant heterogeneity among the included studies, no meta-analysis could be performed. In conclusion, the salivary levels of protein(s) might be a useful biomarker for caries diagnosis, especially alpha-amylase, acidic proline-rich protein-1, histatin-5, lactoperoxidase, mucin-1, carbonic anhydrase 6, proteinase-3, and statherin. However, their diagnostic value must be verified by large-scale prospective studies.
Walsh, T., Macey, R., Ricketts, D., Carrasco Labra, A., Worthington, H., Sutton, A. J., Freeman, S., Glenny, A. M., Riley, P., Clarkson, J., & Cerullo, E. (2022). Enamel Caries Detection and Diagnosis: An Analysis of Systematic Reviews. J Dent Res, 101(3), 261-269.
Detection and diagnosis of caries-typically undertaken through a visual-tactile examination, often with supporting radiographic investigations-is commonly regarded as being broadly effective at detecting caries that has progressed into dentine and reached a threshold where restoration is necessary. With earlier detection comes an opportunity to stabilize disease or even remineralize the tooth surface, maximizing retention of tooth tissue and preventing a lifelong cycle of restoration. We undertook a formal comparative analysis of the diagnostic accuracy of different technologies to detect and inform the diagnosis of early caries using published Cochrane systematic reviews. Forming the basis of our comparative analysis were 5 Cochrane diagnostic test accuracy systematic reviews evaluating fluorescence, visual or visual-tactile classification systems, imaging, transillumination and optical coherence tomography, and electrical conductance or impedance technologies. Acceptable reference standards included histology, operative exploration, or enhanced visual assessment (with or without tooth separation) as appropriate. We conducted 2 analyses based on study design: a fully within-study, within-person analysis and a network meta-analysis based on direct and indirect comparisons. Nineteen studies provided data for the fully within-person analysis and 64 studies for the network meta-analysis. Of the 5 technologies evaluated, the greatest pairwise differences were observed in summary sensitivity points for imaging and all other technologies, but summary specificity points were broadly similar. For both analyses, the wide 95% prediction intervals indicated the uncertainty of future diagnostic accuracy across all technologies. The certainty of evidence was low, downgraded for study limitations, inconsistency, and indirectness. Summary estimates of diagnostic accuracy for most technologies indicate that the degree of certitude with which a decision is made regarding the presence or absence of disease may be enhanced with the use of such devices. However, given the broad prediction intervals, it is challenging to predict their accuracy in any future “real world” context.
Frantsve-Hawley, J., Abt, E., Carrasco-Labra, A., Dawson, T., Michaels, M., Pahlke, S., Rindal, D. B., Spallek, H., & Weyant, R. J. (2022). Strategies for developing evidence-based clinical practice guidelines to foster implementation into dental practice. J Am Dent Assoc, 153(11), 1041-1052.
Background: Professional and other organizations, including oral health care organizations, have been developing evidence-based clinical practice guidelines (CPGs) to help providers incorporate the best available evidence into their clinical decision making. Although the rigor of guideline development has increased over time, ongoing challenges prevent the full adoption of CPGs into clinical practices that experience variability in provider expertise and opinion, patient flow pace, and use of electronic dental records. These challenges include lack of relevant evidence, failure to keep guidelines up to date, and failure to adopt strategies aimed at overcoming the barriers preventing implementation into clinical practice.
Results: This article provides a brief overview of strategies that can be used to overcome common challenges to guideline adoption. Such strategies include creating evidence-based CPGs that use additional sources of evidence and methods to inform guideline development and accelerate the guideline updating and dissemination process (that is, evidence directly from clinical practice, big data, patients’ values and preferences, and living guidelines) and applying implementation strategies that have been documented as improving translation of CPGs into routine clinical practice (that is, guideline implementability, implementation science, and computable guidelines).
Practical implications: Adopting newer strategies for developing and translating evidence into practice could lead to improvements in patient care and population health.
Keywords: Evidence-based dentistry; clinical practice guidelines; computable guidelines; evidence-based medicine; implementability; implementation science; learning health care systems; patients’ values and preferences.
Glick, M., & Carrasco-Labra, A. (2022). Screening testing in health care: Getting it right. J Am Dent Assoc, 153(4), 365-370.
Background: There is a movement to engage oral health care professionals in administering tests to identify people at risk of developing contagious diseases and other medical conditions. The purpose of this overview was to provide clinicians with fundamental concepts to understand how to evaluate a screening test’s capability to give a correct result and its implications for practice (health outcomes).
Types of studies reviewed: The authors reviewed epidemiologic and statistical articles addressing the purpose of performing screening tests for medical conditions with a special emphasis on understanding and interpreting test results on the basis of specific test characteristics.
Results: Tests with different sensitivities and specificities will provide different probabilities of correctly classifying people with or without a disease of interest. By understanding how to interpret tests results and how to communicate the consequences (that is, impact on health outcomes) of positive and negative test results, oral health care professionals will be able to generate appropriate medical referrals and determine the need for further testing, as well as provide a public service.
Conclusions and practical implications: An understanding by oral health care professionals of how to interpret screening test results will benefit their patients substantially and, in the case of contagious diseases, the public at large.
Keywords: Screening tests; disease prevalence; negative predictive value; positive predictive value; sensitivity; specificity.
Azab, M., Ibrahim, S., Li, A., Khosravirad, A., Carrasco-Labra, A., Zeng, L., & Brignardello-Petersen, R. (2022). Efficacy of secondary vs primary closure techniques for the prevention of postoperative complications after impacted mandibular third molar extractions: A systematic review update and meta-analysis. J Am Dent Assoc, 153(10), 943-956 e948.
Background: The aim of this systematic review was to determine whether secondary closure (SC) or primary closure (PC) is better at preventing postoperative complications after impacted mandibular third-molar extraction.
Types of studies reviewed: The authors sought randomized controlled trials comparing the effects of PC and SC on pain, swelling, trismus, infection, and bleeding after impacted mandibular third-molar extraction. Screening, data extraction, and risk of bias assessments were conducted independently and in duplicate. The reviewers pooled results across studies using a random-effects meta-analysis and assessed the certainty of the evidence using the Grading of Recommendations Assessment, Development and Evaluation approach.
Results: This review identified 785 unique citations and included 40 trials. Compared with PC, SC was found to have trivial benefits for pain at day 7 and trismus within 1 week (moderate certainty). The incidence of infection and bleeding did not differ importantly between techniques (moderate certainty). However, SC is probably associated with less swelling on day 1 (standardized mean difference, -0.98; 95% CI, -1.22 to -0.73; moderate certainty) and day 3 (standardized mean difference, -0.87; 95% CI, -1.16 to -0.59; moderate certainty). There was very low certainty evidence for pain on days 1 and 3 and low certainty evidence for swelling on day 7.
Conclusions and practical implications: Clinicians choosing between closure techniques should be aware that SC probably imparts an important benefit only for swelling at days 1 and 3. There seems to be a trivial difference between the techniques in other outcomes.
Keywords: Pain; postoperative complications; primary closure; secondary closure; swelling; third molar; trismus.
Urquhart, O., DeLong, H. R., Ziegler, K. M., Pilcher, L., Pahlke, S., Tampi, M. P., O’Brien, K. K., Patton, L. L., Agrawal, N., Hofstede, T. M., Kademani, D., Lingen, M. W., Treister, N. S., Tsai, C. J., Carrasco-Labra, A., & Lipman, R. D. (2022). Effect of Preradiation Dental Intervention on Incidence of Osteoradionecrosis in Patients with Head and Neck Cancer: A Systematic Review and Meta-Analysis. J Am Dent Assoc, 153(10), 931-942 e932.
Background: The purpose of this systematic review was to examine whether dental intervention involving bone or soft-tissue manipulation preradiotherapy (pre-RT) is associated with lower rates of osteoradionecrosis of the jaw (ORNJ) in patients with head and neck cancer (HNC).
Types of studies reviewed: The authors included relevant studies from MEDLINE, Embase, and Cochrane Library, including observational studies published from 2007 through 2021 and involving adults who underwent dental intervention pre-RT for HNC. Authors assessed evidence certainty by using the Grading of Recommendations Assessment, Development, and Evaluation approach. Random-effects models were used to calculate pooled relative risk estimates and hazard ratios. When meta-analysis was not possible, study-level measures of association and narrative summaries of the evidence were reported.
Results: Twenty-two studies were included. From the pooled, unadjusted analysis, patients undergoing pre-RT extractions may have a 55% increased risk of experiencing ORNJ (relative risk, 1.55; 95% CI, 0.85 to 2.86; very low certainty); the unadjusted pooled hazard ratio was 3.19 (95% CI, 0.99 to 10.31; very low certainty), corresponding to a possible increased hazard of developing ORNJ (very low certainty). Findings for other pre-RT procedures manipulating bone or tissue relied on limited, observational studies with low or very low certainty evidence.
Conclusions: Mostly very low certainty evidence suggests that patients with HNC who need pre-RT dental intervention may have an increased risk of developing ORNJ compared with those who do not.
Practical implications: Maintaining optimal oral health may help reduce the need for urgent pre-RT dental treatment, potentially reducing ORNJ risk and minimizing delay of oncologic treatment in patients with HNC.
Keywords: Head and neck cancer; dental intervention; medically complex; osteoradionecrosis; radiation.
Zhang, Y. Q., Jiao, R. M., Witt, C. M., Lao, L., Liu, J. P., Thabane, L., Sherman, K. J., Cummings, M., Richards, D. P., Kim, E. A., Kim, T. H., Lee, M. S., Wechsler, M. E., Brinkhaus, B., Mao, J. J., Smith, C. A., Gang, W. J., Liu, B. Y., Liu, Z. S., Zheng, H., Wu, J.N., Carrasco-Labra, A., Bhandar, M., Devereaux, P.J., Jing, X.H., Guyatt, G. (2022). How to Design High Quality Acupuncture Trials — A Consensus Informed By Evidence. BMJ, 376, e067476.
An international panel including patients, clinicians, researchers, acupuncture and surgery trialists, statisticians, and experts in clinical epidemiology and methodology have developed new guidance for randomized controlled trials in acupuncture. It addresses the most prevalent and critical concerns of current acupuncture trials and will help funding agencies, trial registers, and journal editors to evaluate the relevance, importance, and quality of submitted trial proposals and completed trials.
Zhang, Y. Q., Lu, L., Xu, N., Tang, X., Shi, X., Carrasco-Labra, A., Schunemann, H., Chen, Y., Xia, J., Chen, G., Liu, J., Liu, B., Wang, J., Qaseem, A., Jing, X., Guyatt, G., & Zhao, H. (2022). Increasing the Usefulness of Acupuncture Guideline Recommendations. BMJ, 376, e070533.
Yu-Qing Zhang and colleagues examine the progress and pitfalls in guideline recommendations for acupuncture and provide suggestions for improvement.
Carrasco-Labra, A., Devji, T., Qasim, A., Phillips, M., Johnston, B. C., Devasenapathy, N., Zeraatkar, D., Bhatt, M., Jin, X., Brignardello-Petersen, R., Urquhart, O., Foroutan, F., Schandelmaier, S., Pardo-Hernandez, H., Vernooij, R. W., Huang, H., Rizwan, Y., Siemieniuk, R., Lytvyn, L., . . . Guyatt, G. H. (2022). Serious Reporting Deficiencies Exist in Minimal Important Difference Studies: Current State and Suggestions for Improvement. J Clin Epidemiol, 150, 25-32.
Background and objectives: To evaluate reporting of minimal important difference (MID) estimates using anchor-based methods for patient-reported outcome measures (PROMs), and the association with reporting deficiencies on their credibility.
Methods: Systematic survey of primary studies empirically estimating MIDs. We searched Medline, EMBASE, PsycINFO, and the Patient-Reported Outcome and Quality of Life Instruments Database until October 2018. We evaluated study reporting, focusing on participants’ demographics, intervention(s), characteristics of PROMs and anchors, and MID estimation method(s). We assessed the impact of reporting issues on credibility of MID estimates.
Results: In 585 studies reporting on 5,324 MID estimates for 526 distinct PROMs, authors frequently failed to adequately report key characteristics of PROMs and MIDs, including minimum and maximum values of PROM scale, measure of variability accompanying the MID estimate and number of participants included in the MID calculation. Across MID estimates (n = 5,324), the most serious reporting issues impacting credibility included infrequent reporting of the correlation between the anchor and PROM (66%), inadequate details to judge precision of MID point estimate (13%), and insufficient information about the threshold used to ascertain MIDs (16%).
Conclusion: Serious issues of incomplete reporting in the MID literature threaten the optimal use of MID estimates to inform the magnitude of effects of interventions on PROMs.
Keywords: Anchor-based methods; Credibility; Minimal important difference; Patient-reported outcome; Reporting quality; Systematic survey.
Wang, Y., Devji, T., Qasim, A., Hao, Q., Wong, V., Bhatt, M., Prasad, M., Wang, Y., Noori, A., Xiao, Y., Ghadimi, M., Lozano, L. E. C., Phillips, M. R., Carrasco-Labra, A., King, M., Terluin, B., Terwee, C. B., Walsh, M., Furukawa, T. A., & Guyatt, G. H. (2022). A Systematic Survey Identified Methodological Issues in Studies Estimating Anchor-Based Minimal Important Differences in Patient-Reported Outcomes. J Clin Epidemiol, 142, 144-151.
Objective: To systematically survey the literature addressing the reporting of studies estimating anchor-based minimal important differences (MIDs) and choice of optimal MIDs.
Study design and setting: We searched Medline, Embase and PsycINFO from 1987 to March 2020. Teams of two reviewers independently identified eligible publications and extracted quotations addressing relevant issues for reporting and/or selecting anchor-based MIDs. Using a coding list, we assigned the same code to quotations capturing similar or related issues. For each code, we generated an ‘item’, i.e., a specific phrase or sentence capturing the underlying concept. When multiple concepts existed under a single code, the team created multiple items for that code. We clustered codes addressing a broader methodological issue into a ‘category’ and classified items as relevant for reporting, relevant for selecting an anchor-based MID, or both.
Results: We identified 136 eligible publications that provided 6 categories (MID definition, anchors, patient-reported outcome measures, generalizability and statistics) and 24 codes. These codes contained 34 items related to reporting MID studies, of which 29 were also related to selecting MIDs.
Conclusion: The systematic survey identified items related to reporting of anchor-based MID studies and selecting optimal MIDs. These provide a conceptual framework to inform the design of studies related to MIDs, and a basis for developing a reporting standard and a selection approach for MIDs.
Keywords: Minimal important difference; Patient-reported outcome measure; systematic survey.
Tsujimoto, Y., Fujii, T., Tsutsumi, Y., Kataoka, Y., Tajika, A., Okada, Y., Carrasco-Labra, A., Devji, T., Wang, Y., Guyatt, G. H., & Furukawa, T. A. (2022). Minimal Important Changes in Standard Deviation Units are Highly Variable and No Universally Applicable Value Can be Determined. J Clin Epidemiol, 145, 92-100.
Objectives: This study aims to describe the distribution of anchor-based minimal important change (MIC) estimates in standard deviation (SD) units and examine if the robustness of such estimates depends on the specific SD used or on the methodological credibility of the anchor-based estimates.
Design and setting: We included all anchor-based MIC estimates from studies published in MEDLINE and relevant literature databases upto October 2018. Each MIC was converted to SD units using baseline, endpoint, and change from baseline SDs. We performed a descriptive analysis of MICs in SD units and checked how the distribution would change if MICs with low methodological credibility were excluded from the analysis.
Results: We included 1,009 MIC estimates from 182 studies. The medians and interquartile ranges of MICs in SD units were 0.43 (0.25 to 0.69), 0.42 (0.22 to 0.70), and 0.51 (0.28 to 0.78) for baseline, endpoint, and change SD units, respectively. Some MICs were extremely large or small. The distribution did not change significantly after excluding MICs estimated by less credible methods.
Conclusions: The size of the universally applicable MIC in SD units could not be determined. Anchor-based MICs in SD units were widely distributed, with more than half in the range of 0.2 to 0.8.
Keywords: Minimal important change; anchor-based method; distribution-based method; effect size; patient-reported outcome.
Tampi, M., Carrasco-Labra, A., O’Brien, K. K., Velandia-Gonzalez, M., & Brignardello-Petersen, R. (2022). Systematic Review on Reducing Missed Opportunities for Vaccinations in Latin America. Rev Panam Salud Publica, 46, e65.
Objectives: To estimate the prevalence of missed opportunities for vaccination (MOV) in Latin America and the effect of interventions targeting health systems, health workers, patients, and communities on MOV.
Methods: Searches were conducted in MEDLINE, EMBASE, CINAHL, and LILACS electronic databases and relevant organizations were contacted, including the Pan American Health Organization (PAHO), to identify studies meeting eligibility criteria. A pair of reviewers identified 27 randomized and non-randomized studies quantifying the effectiveness of any intervention for reducing MOV and 5 studies assessing the rate of MOV in Latin America. Results are reported narratively when criteria to pool results were not met, and the certainty of this evidence was assessed using the GRADE approach.
Results: Evidence suggests the rate of MOV in Latin America ranged from 5% to 37% with a pooled estimate of 17% (95% CI [9, 32]) (low certainty) and that monetary incentives to healthcare teams, training for healthcare teams on how to communicate with patients, and educational interventions for caregivers probably reduce MOV (moderate to very low certainty).
Conclusions: There is insufficient evidence supporting the implementation of any intervention as policy based only on the potential reduction of MOV without considering several factors, including costs, feasibility, acceptability, and equity.
Keywords: Latin America; Vaccination; immunization; vaccination coverage.
France, K., & Glick, M. (2022). Long COVID and Oral Health Care Considerations. J Am Dent Assoc, 153(2), 167-174.
Background: People who have recovered from the initial severe acute respiratory syndrome coronavirus 2 infection are at risk of developing long COVID, a prolonged suite of signs and symptoms that may interfere with daily life and the ability to undergo routine oral health care.
Methods: The available literature on long COVID was reviewed and compiled to produce a review of the syndrome as currently understood. Articles were evaluated with a focus on how long COVID may affect the provision of oral health care and on ways in which treatment may need to be modified to best care for this vulnerable patient population.
Results: Long COVID includes a wide variety of symptoms, such as fatigue, shortness of breath, chest pain, risk of developing thromboembolism, and neurologic and psychiatric complications. These symptoms may arise at various times and in a wide range of patients, and they may necessitate modification of routine oral health care interventions.
Conclusions: Recommendations for the treatment of affected people in an oral health care setting are presented, including a thorough evaluation of the patient history and current status, understanding of how related symptoms may affect oral health care interventions, and which modifications to treatment are needed to provide safe and appropriate care.
Practical implications: Oral health care professionals must be aware of long COVID, an increasingly prevalent condition with a widely variable presentation and impact. Oral health care professionals should be prepared to treat these patients safely in an outpatient oral health setting.
Keywords: COVID-19; Long COVID; medically complex dental treatment; patient treatment.
Wolff, M. S., & Glick, M. (2021). COVID-19 Vaccination: To Lead by Example or an Opportunity Lost. J Dent Res, 100(13), 1421-1422.
Coronavirus disease 2019 (COVID-19) has created a global health emergency. Vaccine hesitancy and tremendous misinformation about the actual science are leaving the public with significant confusion. However, sound epidemiologic science is guiding us to a clear path toward mitigating this modern-day scourge. It is remarkable how putting an end to current COVID-19 outbreaks has such a simple solution-convincing the public to accept getting vaccinated. The dental research, dental education, and dental practice communities have a unique opportunity to act as trusted public exemplars as well as trusted interpreters of the science for the public.
