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Direct Materials for Restoring Caries Lesions: Systematic Review and Meta-analysis -- A Report of the American Dental Association Council on Scientific Affairs

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.

PubMed | DOI

Direct Materials for Restoring Caries Lesions: Systematic Review and Meta-analysis -- A Report of the American Dental Association Council on Scientific Affairs.

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.

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Injectable and Topical Local Anesthetics for Acute Dental Pain: 2 Systematic Reviews

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.

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The Association between Accessing Dental Services and Nonventilator Hospital-acquired Pneumonia among 2019 Medicaid Beneficiaries

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.

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Incidence, Mortality, and Cost Trends in Nonventilator Hospital-acquired Pneumonia in Medicaid Beneficiaries

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.

PubMed | DOI

Salivary Proteins as Dental Caries Biomarkers: A Systematic Review

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.

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Enamel Caries Detection and Diagnosis: An Analysis of Systematic Reviews

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.

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Strategies for Developing Evidence-based Clinical Practice Guidelines to Foster Implementation into Dental Practice

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.

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Words and Concepts Matter

Glick, M., & Ackerman, M. (2022). Words and concepts matter. Quintessence Int, 53(9), 741-742.

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Screening Testing in Health Care: Getting it Right

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.

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COVID-19 and Scientific Illiteracy, A Syndemic

Glick, M., Wolff, M. S., & Carrasco-Labra, A. (2021). COVID-19 and scientific illiteracy, a syndemic. J Am Dent Assoc, 152(12), 967-968.

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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

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.

PubMed | DOI

Pigmented Demodicidosis - An Under-Recognized Cause of Facial Hyperpigmentation

Feuerman, H., Atzmony, L., Glick, M., Sherman, S., Snast, I., Hodak, E., & Segal, R. (2022). Pigmented Demodicidosis – An Under-Recognized Cause of Facial Hyperpigmentation. Int J Dermatol, 61(5), 564-569.

Background: There is a paucity of data regarding demodicidosis-associated facial hyperpigmentation.

Objective: To delineate the clinical, dermoscopic, and histopathologic features of demodicidosis-associated facial hyperpigmentation.

Methods: Clinical and diagnostic data were collected from the medical files of patients who were referred to our outpatient dermatology clinic in 2006-2019 for evaluation of facial hyperpigmentation and were diagnosed with demodicidosis.

Results: The cohort included 19 patients (13 male) aged 42-76 years, all with Fitzpatrick skin type 3-4. All presented with mostly asymptomatic dusky, brown-gray, facial pigmentation, localized or diffuse with background erythema in 36.8% of cases, and skin roughness in 26.3%. Dermoscopy yielded characteristic findings of white gelatinous or opaque protrusions from hair follicles or infiltration of follicular openings with an amorphic material. A specific finding was perifollicular and reticulated pigmentation of the affected areas. Findings were confirmed on microscopic (n = 7) and histopathologic (n = 5) studies. Anti-demodectic treatment led to complete (73.6%) or partial (23.4%) resolution of pigmentation within 2 years.

Conclusion: We describe unique clinicopathological and dermoscopic findings associated with an under-recognized type of facial hyperpigmentation caused by demodex for which we propose the term “pigmented demodicidosis.” Demodicidosis should be added to the list of causes of facial hyperpigmentation.

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Effect of Preradiation Dental Intervention on Incidence of Osteoradionecrosis in Patients with Head and Neck Cancer: A Systematic Review and Meta-Analysis

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.

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Pain, Analgesic Use, and Patient Satisfaction With Spinal Versus General Anesthesia for Hip Fracture Surgery : A Randomized Clinical Trial

Neuman, M. D., Feng, R., Ellenberg, S. S., Sieber, F., Sessler, D. I., Magaziner, J., Elkassabany, N., Schwenk, E. S., Dillane, D., Marcantonio, E. R., Menio, D., Ayad, S., Hassan, M., Stone, T., Papp, S., Donegan, D., Marshall, M., Jaffe, J. D., Luke, C., . . .Glick, M.,… Investigators, R. (2022). Pain, Analgesic Use, and Patient Satisfaction With Spinal Versus General Anesthesia for Hip Fracture Surgery : A Randomized Clinical Trial. Ann Intern Med, 175(7), 952-960.

Background: The REGAIN (Regional versus General Anesthesia for Promoting Independence after Hip Fracture) trial found similar ambulation and survival at 60 days with spinal versus general anesthesia for hip fracture surgery. Trial outcomes evaluating pain, prescription analgesic use, and patient satisfaction have not yet been reported.

Objective: To compare pain, analgesic use, and satisfaction after hip fracture surgery with spinal versus general anesthesia.

Design: Preplanned secondary analysis of a pragmatic randomized trial. (ClinicalTrials.gov: NCT02507505).

Setting: 46 U.S. and Canadian hospitals.

Participants: Patients aged 50 years or older undergoing hip fracture surgery.

Intervention: Spinal or general anesthesia.

Measurements: Pain on postoperative days 1 through 3; 60-, 180-, and 365-day pain and prescription analgesic use; and satisfaction with care.

Results: A total of 1600 patients were enrolled. The average age was 78 years, and 77% were women. A total of 73.5% (1050 of 1428) of patients reported severe pain during the first 24 hours after surgery. Worst pain over the first 24 hours after surgery was greater with spinal anesthesia (rated from 0 [no pain] to 10 [worst pain imaginable]; mean difference, 0.40 [95% CI, 0.12 to 0.68]). Pain did not differ across groups at other time points. Prescription analgesic use at 60 days occurred in 25% (141 of 563) and 18.8% (108 of 574) of patients assigned to spinal and general anesthesia, respectively (relative risk, 1.33 [CI, 1.06 to 1.65]). Satisfaction was similar across groups.

Limitation: Missing outcome data and multiple outcomes assessed.

Conclusion: Severe pain is common after hip fracture. Spinal anesthesia was associated with more pain in the first 24 hours after surgery and more prescription analgesic use at 60 days compared with general anesthesia.

Primary funding source: Patient-Centered Outcomes Research Institute.

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How to Design High Quality Acupuncture Trials -- A Consensus Informed By Evidence

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.

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Increasing the Usefulness of Acupuncture Guideline Recommendations

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.

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Serious Reporting Deficiencies Exist in Minimal Important Difference Studies: Current State and 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.

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A Systematic Survey Identified Methodological Issues in Studies Estimating Anchor-Based Minimal Important Differences in Patient-Reported Outcomes

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.

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Minimal Important Changes in Standard Deviation Units are Highly Variable and No Universally Applicable Value Can be Determined

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.

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Systematic Review on Reducing Missed Opportunities for Vaccinations in Latin America

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.

PubMed | DOI

Long COVID and Oral Health Care Considerations

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.

PubMed | DOI

COVID-19 Vaccination: To Lead by Example or an Opportunity Lost

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.

PubMed | DOI

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