Search

Background: Pain dysfunction syndrome (PDS) is the most common temporomandibular disorder (TMD). There are many synonyms for this condition including facial arthromylagia, TMJ dysfunction syndrome, myofacial pain dysfunction syndrome, craniomandibular dysfunction and myofacial pain dysfunction. The aetiology of PDS is multifactorial and many different therapies have been advocated., Objectives: To establish the effectiveness of stabilisation splint therapy in reducing symptoms in patients with pain dysfunction syndrome., Search Strategy: Electronic databases (including the Cochrane Oral Health Group's Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); The Cochrane Library Issue 2, 2003; MEDLINE (1966 to June 2001); EMBASE (1966 to June 2001)) were searched. Handsearching of relevant journals was undertaken and reference lists of included studies screened. Experts in the field were contacted to identify unpublished articles. There was no language restriction., Selection Criteria: Randomised or quasi-randomised controlled trials (RCTs), in which splint therapy was compared concurrently to no treatment, other occlusal appliances, or any other active intervention., Data Collection and Analysis: Data extraction was carried out independently and in duplicate. Validity assessment of the included trials was carried out at the same time as data extraction. Discrepancies were discussed and a third reviewer consulted. The author of the primary study was contacted where necessary. The studies were grouped according to treatment type and duration of follow up., Main Results: Twenty potentially relevant RCTs were identified. Eight trials were excluded leaving 12 RCTs for analysis. Stabilisation splint therapy was compared to: acupuncture, bite plates, biofeedback/stress management, visual feedback, relaxation, jaw exercises, non-occluding appliance and minimal/no treatment. There was no evidence of a statistically significant difference in the effectiveness of stabilisation splint therapy (SS) in reducing symptoms in patients with pain dysfunction syndrome compared with other active treatments. There is weak evidence to suggest that the use of SS for the treatment of PDS may be beneficial for reducing pain severity, at rest and on palpation, when compared to no treatment., Reviewer's Conclusions: There is insufficient evidence either for or against the use of stabilisation splint therapy for the treatment of temporomandibular pain dysfunction syndrome. This review suggests the need for further, well conducted RCTs that pay attention to method of allocation, outcome assessment, large sample size, and enough duration of follow up. A standardisation of the outcomes of the treatment of PDS should be established in the RCTs.

Aims: To carry out a systematic review of previous studies to determine the effectiveness of any intervention vs placebo for relief of symptoms and improvement in quality of life of patients with burning mouth syndrome (BMS) and to assess the quality of the studies., Methods: Electronic databases, conference proceedings, and bibliographies of identified publications were searched (up to September 2001) to identify relevant literature, irrespective of language of publication. Randomized controlled trials and controlled clinical trials of interventions used for the treatment of BMS in comparison to a placebo were included. The primary outcome was relief of burning/discomfort. The screening of studies, validity assessment, and data extraction were undertaken independently and in duplicate. Since statistical pooling of data was inappropriate, a qualitative assessment was undertaken., Results: Seven trials, evaluating antidepressants, cognitive behavioral therapy, analgesics, hormone replacement therapy, and vitamin complexes, met the inclusion criteria. None of the trials was able to provide conclusive evidence of effectiveness. However, cognitive behavioral therapy may be beneficial in reducing the intensity of the symptoms., Conclusion: Given that the research evidence is, as yet, unable to provide clear, conclusive evidence of an effective intervention, clinicians need to provide support and understanding when dealing with BMS sufferers. Psychological interventions that help patients to cope with symptoms may be of some use, but promising and new approaches to treatment still need to be evaluated in good-quality randomized controlled trials.

The aim of this study was to assess the quality of systematic reviews of effectiveness of interventions in dentistry. The Database of Abstracts of Reviews of Effectiveness and the Cochrane Database of Systematic Reviews were searched to identify systematic reviews examining the effectiveness of interventions for oral, dental and craniofacial disorders and diseases. Sixty-five reviews were identified and assessed independently by two reviewers. The area most frequently evaluated within the reviews was pain relief/prevention (20/65, 31%) followed by caries and oral medicine. The quality assessment of the identified systematic reviews highlighted key areas where improvements could be made. One major weakness of the reviews was that the search strategies employed were not always adequate. Only 12 reviews (19%) demonstrated an attempt to identify all relevant studies. Other areas of weakness include the screening and quality assessment of primary studies, the pooling of data and examination of heterogeneity, and the interpretation of findings. This investigation shows that the quality of systematic reviews in dentistry could be improved. If future clinical decisions are to be based upon systematic reviews, it is imperative that the reviews address clinically relevant, focused questions and follow a 'transparent', well-designed protocol.

Objective: To determine the validity of adjusted indirect comparisons by using data from published meta-analyses of randomised trials., Design: Direct comparison of different interventions in randomised trials and adjusted indirect comparison in which two interventions were compared through their relative effect versus a common comparator. The discrepancy between the direct and adjusted indirect comparison was measured by the difference between the two estimates., Data Sources: Database of abstracts of reviews of effectiveness (1994-8), the Cochrane database of systematic reviews, Medline, and references of retrieved articles., Results: 44 published meta-analyses (from 28 systematic reviews) provided sufficient data. In most cases, results of adjusted indirect comparisons were not significantly different from those of direct comparisons. A significant discrepancy (P<0.05) was observed in three of the 44 comparisons between the direct and the adjusted indirect estimates. There was a moderate agreement between the statistical conclusions from the direct and adjusted indirect comparisons (kappa 0.51). The direction of discrepancy between the two estimates was inconsistent., Conclusions: Adjusted indirect comparisons usually but not always agree with the results of head to head randomised trials. When there is no or insufficient direct evidence from randomised trials, the adjusted indirect comparison may provide useful or supplementary information on the relative efficacy of competing interventions. The validity of the adjusted indirect comparisons depends on the internal validity and similarity of the included trials.

Background: Dental decay in primary teeth remains a considerable health problem. Where decay extends to involve the dental pulp, pulp treatment techniques are often used to manage both symptomatic and symptom free teeth., Objectives: To assess the relative effectiveness of: various pulp treatment techniques in retaining primary molar teeth with decay involving the pulp for at least 12 months; pulp treatment techniques and extractions in avoiding long term sequelae., Search Strategy: We searched the Cochrane Oral Health Group's Trials Register (August 2002); the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 3, 2002); MEDLINE (January 1966 to August 2002); EMBASE (1980 to August 2002); Science Citation Index Expanded (1981 to August 2002); Social Science Citation Index (1981 to August 2002); Index to Scientific and Technical Proceedings (1982 to August 2002); System for Information on Grey Literature in Europe (August 2002). Key journals were handsearched. There was no restriction on language of publication., Selection Criteria: Randomised or quasi-randomised controlled trials (RCTs) comparing different pulp treatment techniques (with each other, with extraction or with no treatment) for extensive decay in primary molar teeth. Primary outcomes were extractions following pulp treatment and long term effects., Data Collection and Analysis: Data extraction and quality assessment were carried out independently and in duplicate. Authors were contacted for additional information where necessary., Main Results: Eighty-two studies were identified but only three were suitable for inclusion. Nine studies meeting the inclusion criteria but with inappropriate study design or analysis are also described. Included trials investigated formocresol pulpotomy, ferric sulphate pulpotomy, electrosurgical pulpotomy or zinc oxide eugenol pulpectomy in symptom free, cariously exposed teeth. Data were unavailable on long term effects. Data on extraction following pulp treatment was available in all three studies and in two studies there was no statistically significant difference between the treatments. The difference seen in the other study, where more teeth treated by ferric sulphate pulpotomy were extracted compared to zinc oxide eugenol pulpectomy, must be viewed with caution., Reviewer's Conclusions: Based on the available RCTs, there is no reliable evidence supporting the superiority of one type of treatment for pulpally involved primary molars. No conclusions can be made as to the optimum treatment or techniques for pulpally involved primary molar teeth due to the scarcity of reliable scientific research. High quality RCTs, with appropriate unit of randomisation and analysis are needed.

Aims: To assess general dental practitioners' understanding of, and attitudes towards, evidence based practice (EBP)., Subjects: A random sample of general dental practitioners currently practising in the North West of England., Method: A cross-sectional survey using self administered, structured, postal questionnaires in January 2001., Results: A majority of the respondents had some understanding of technical terms associated with EBP. Only 29% (60/204) could correctly define the term EBP. When faced with clinical uncertainties 60% (122/204) of general dental practitioners turned to friends and colleagues for help and advice. Eighty one percent of respondents were interested in finding out further information about EBP (165/204). Barriers to its use included a lack of available time and financial constraints., Conclusions: EBP is not a concept that every dentist is familiar with, however, the general dental practitioners surveyed were enthusiastic and expressed a desire to find out more information on EBD. It appears to be the right time for an educational program targeted at GDPs to enhance their knowledge and use of EBD in everyday practice.

Objective: To devise a taxonomy for the assessment of the orthodontic literature on methods described to effect distal movement of maxillary molars, to test the taxonomy for inter-assessor reliability, and to use it to classify studies in a systematic review of the literature., Data Sources: Articles appearing in the American Journal of Orthodontics and Dentofacial Orthopedics, Angle Orthodontist, (British) Journal of Orthodontics, European Journal of Orthodontics, and the Journal of Clinical Orthodontics between 1988 and 1998. Data selection Articles describing or evaluating the effect of appliances known or thought to have a distalizing effect on maxillary molars., Data Extraction: A taxonomy was designed, tested by two reviewers independently to assess levels of agreement, and then used to record the features of the articles in a systematic review of the literature., Data Synthesis: Kappa scores were used to assess the level of agreement between reviewers and found to be satisfactory. Studies were grouped according to study design and features of their methodology quantified., Conclusions: Having devised and tested the taxonomy, we found that the quality of evidence for any method of moving maxillary molars distally was not high.

The objective of this article was twofold (1) to determine the existence and effectiveness of interventions to improve health professionals' management of obesity or the organization of care for overweight and obese people; and (2) to update a previous systematic review on this topic with new or additional studies. The study design was a systematic review of intervention studies, undertaken according to standard methods developed by the Cochrane Effective Practice and Organization of Care (EPOC) Group. Participants were trained health care professionals and overweight and obese patients. The measurements were objective measures of health professionals' practice and behaviours, and patient outcomes including satisfaction, behaviour, psychological factors, disease status, risk factors and measures of body weight, fat, or body mass index (BMI). Twelve studies were included in the original review. A further six were included in this update. Six of the 18 studies were randomized controlled trials of health professional-oriented interventions (such as the use of reminders and training) and one was a controlled before-and-after study to improve collaboration between a hospital clinic and general practitioners (GPs). Ten randomized controlled trials and two controlled clinical trials of interventions comparing either the deliverer of weight-loss interventions or the setting of the delivery of the intervention, were identified. The heterogeneity and generally limited quality of identified studies make it difficult to provide recommendations for improving health professionals' obesity management. To conclude, at present, there are few solid leads about improving obesity management, although reminder systems, brief training interventions, shared care, inpatient care and dietitian-led treatments may all be worth further investigation. Therefore, decisions for the improvement of provision of services must be based on the existing evidence on interventions with patients and good clinical judgement. Further research is needed to identify cost-effective strategies for improving the management of obesity. A full version of this review (including detailed descriptions of the included studies and their methodological quality, and results and excluded studies tables) is available in the Cochrane Library. The Cochrane Library is a database of systematic review and other evidence on the effects of health care, continuously updated as new information emerges. It is available on CD ROM from Update Software. For further information see: http://www.update-software.com/cochrane.

Objectives: To conduct a systematic review of epidemiological literature in order to determine the prevalence and associated risk factors of oro-facial pain., Data: Population based observational studies (cohorts, cross-sectional and case-control studies) of oro-facial pain, published in the English language, prior to 1999 were included., Sources: Electronic databases (Medline, Embase, Cinahl, BIDS and Health CD) were searched. Reference lists of relevant articles were examined, and the journals "Pain" and "Community Dentistry and Oral Epidemiology" were handsearched for the years 1994-1998., Results: The results of the search strategy were screened for relevance. A standardised checklist was used to assess the methodological quality of each study by two reviewers before an attempt was made to summarise the results. The median quality score was 70% of the maximum attainable score. Due to methodological issues, it was not possible to pool the data on the prevalence of oro-facial pain. Age, gender and psychological factors were found to be associated with OFP, however there was not enough information on other factors such as local mechanical and co-morbidities to draw any reliable conclusions. None of the factors fully fulfilled criteria for causality., Conclusions: There is a need for good quality epidemiological studies of oro-facial pain in the general population. To enable comprehensive examination of the aetiology of oro-facial pain, it is necessary to address a broad range of factors including demography and life-style, local mechanical factors, medical history and psychological factors. Future studies should recruit adequately sized samples for precise determination of the prevalence and detection of important associated factors. Data on potential confounders and effect modifiers should also be collected and adjusted for in the statistical analysis.

Background: The complaint of a burning sensation in the mouth can be said to be a symptom of other disease or a syndrome in its own right of unknown aetiology. In patients where no underlying dental or medical causes are identified and no oral signs are found, the term burning mouth syndrome (BMS) should be used. The prominent feature is the symptom of burning pain which can be localised just to the tongue and/or lips but can be more widespread and involve the whole of the oral cavity. Reported prevalence rates in general populations vary from 0.7% to 15%. Many of these patients show evidence of anxiety, depression and personality disorders., Objectives: The objectives of this review are to determine the effectiveness and safety of any intervention versus placebo for relief of symptoms and improvement in quality of life and to assess the quality of the studies., Search Strategy: Electronic databases (The Cochrane Library, the Cochrane Oral Health Group's Specialised Register, MEDLINE, EMBASE), Clinical Evidence Issue No. 3, conference proceedings and bibliographies of identified publications were searched to identify the relevant literature, irrespective of language of publication., Selection Criteria: Studies were selected if they met the following criteria: study design - randomised controlled trials (RCTs) and controlled clinical trials (CCTs) which compared a placebo against one or more treatments; participants - patients with burning mouth syndrome, that is, oral mucosal pain with no dental or medical cause for such symptoms; interventions - all treatments that were evaluated in placebo-controlled trials; primary outcome - relief of burning/discomfort, Data Collection and Analysis: Articles were screened independently by two reviewers to confirm eligibility and extract data. The reviewers were not blinded to the identity of the studies. The quality of the included trials was assessed independently by two reviewers, with particular attention given to allocation concealment, blinding and the handling of withdrawals and drop-outs. Due to differences in patient type, treatment and outcome measures, statistical pooling of the data was inappropriate., Main Results: Six trials were included in the review. The interventions examined were antidepressants (two trials), cognitive behavioural therapy (one trial), analgesics (one trial), hormone replacement therapy (one trial) and vitamin complexes (one trial). The participants included in the six identified trials reported suffering from BMS from six months to 20 years. Diagnostic criteria were not always clearly reported. Out of the six trials included in the review, only two interventions demonstrated a reduction in BMS symptoms; vitamin complexes and cognitive behavioural therapy. Neither of these studies reported using blind outcome assessment. Although none of the other treatments examined in the included studies demonstrated a significant reduction in BMS symptoms, this may be due to methodological flaws in the trial design, or small sample size, rather than a true lack of effect., Reviewer's Conclusions: Given the chronic nature of BMS, the need to identify an effective mode of treatment for sufferers is vital. However, there is little research evidence that provides clear guidance for those treating patients with BMS. Further trials, of high methodological quality, need to be undertaken in order to establish effective forms of treatment for patients suffering from BMS.

This paper aims to explore the potential usefulness and limitations of indirect comparisons in evaluating the relative efficacy of interventions. From a systematic review of antimicrobial prophylaxis in colorectal surgery, we identified 11 sets of randomized trials that can be used to compare antibiotics both directly and indirectly. The discrepancy between the direct and the indirect comparison is defined as the absolute value of difference in log odds ratio. The adjusted indirect comparison has the advantages that the prognostic factors of participants in different trials can be partially taken into account and more uncertainty be incorporated into its result by providing a wider confidence interval. However, considerable discrepancies exist between the direct and the adjusted indirect comparisons. When there is no direct comparison, the adjusted indirect method may be used to obtain some evidence about the relative efficacy of competing interventions, although such indirect results should be interpreted with great caution. Further empirical and methodologic research is needed to explore the validity and generalizability of the adjusted indirect comparison for evaluating different interventions.

Background: There is need for good quality data on congenital anomalies for monitoring (1) interventions for primary prevention and (2) prenatal diagnosis with advice on termination of affected pregnancies., Method: A register was compiled of congenital anomalies arising among births to Leeds residents in an 18 month period (13,596) and terminations (3015) in a related pregnancy cohort. Multiple sources of ascertainment were used and the full range of structural anomalies was included., Results: The total incidence of anomalies (excluding spontaneous abortions) was 1.31 per cent. Incidence rates for the major categories are reported and compared with birth prevalence rates from British studies in the 1950-1960s. It was found that 31.3 per cent of the known anomalies were aborted; 2.26 per cent of the legal abortions were for a congenital anomaly. The overall birth prevalence rate was 1.10 per cent. Neural tube defects are used as an example of the use of a local congenital anomalies register in auditing preventive measures., Conclusion: A local congenital anomalies register is a valuable instrument in monitoring the impact of preventive measures, but it should include data on legal terminations as well as cases detected at birth and subsequently.

This article summarises the findings of a systematic review of the literature concerning antimicrobial prophylaxis before colorectal surgery. From analysing 152 clinical trials certain conclusions can be drawn, such as the importance of ensuring that prophylactic therapy is active against both aerobic and anaerobic bacteria; and, single dose treatment can be as effective as a full course of antibiotics.

Background: A systematic review was carried out to assess the relative efficacy of antimicrobial prophylaxis for the prevention of postoperative wound infection in patients undergoing colorectal surgery., Methods: MEDLINE, EMBASE, the Cochrane Trials Register and the references cited in retrieved studies were searched to identify relevant trials published between 1984 and 1995., Results: Some 147 relevant trials were identified. The quality of trials has improved over the past 12 years. The results confirm that the use of antimicrobial prophylaxis is effective for the prevention of surgical wound infection after colorectal surgery. There was no significant difference in the rate of surgical wound infections between many different regimens. However, certain regimens appear to be inadequate (e.g. metronidazole alone, doxycycline alone, piperacillin alone, oral neomycin plus erythromycin on the day before operation). A single dose administered immediately before the operation (or short-term use) is as effective as long-term postoperative antimicrobial prophylaxis (odds ratio 1.17 (95 per cent confidence interval (c.i.) 0.90-1.53)). There is no convincing evidence to suggest that the new-generation cephalosporins are more effective than first-generation cephalosporins (odds ratio 1.07 (95 per cent c.i. 0.54-2.12))., Conclusion: Antibiotics selected for prophylaxis in colorectal surgery should be active against both aerobic and anaerobic bacteria. Administration should be timed to make sure that the tissue concentration of antibiotics around the wound area is sufficiently high when bacterial contamination occurs. Guidelines should be developed locally in order to achieve a more cost-effective use of antimicrobial prophylaxis in colorectal surgery.

Objective: To determine the effectiveness of interventions designed to prevent and treat obesity, and maintain weight loss., Design: A systematic review of randomised controlled trials., Subjects: Overweight and obese adults and children., Measurements: Post-intervention changes in weight, fat content and fat distribution, measured relative to baseline., Results: For obese children, family therapy and lifestyle modification appear to be effective in prevention and treatment, respectively. The effectiveness of interventions to prevent and treat obesity in adults remains unclear, although behavioural therapy and multicomponent strategies may be useful. Continued therapist contact appears to be useful for maintaining weight loss. Pharmacological interventions appear to be effective for up to 9 months, after which regain occurs. Surgery appears to be effective for the morbidly obese and gastric bypass is more effective than gastroplasty. In general, the methodological quality of studies was poor., Conclusion: Due to problems with methodological quality, it is recommended that research findings indicative of promising interventions are replicated.

A systematic review of the literature on the treatment and prevention of obesity carried out by the NHS Centre for Reviews and Dissemination (CRD) demonstrates that the prevalence of excess weight and obesity are on the increase. The review indicates that certain interventions in primary care can be effective, while surgery appears to be most effective in severe obesity. It highlights limitations in the available research in the area. The article is abstracted from the April 1997 issue of Effective Health Care published by the NHS CRD.

Objective: To evaluate published reviews of the appropriateness of prophylactic removal of impacted third molars., Design: Systematic review and critical appraisal of relevant reviews., Methods: Computerised databases (Medline and Embase), the Index to Dental Literature, and the references of articles were searched to identify relevant reviews., Main Outcome Measures: Pathologies associated with impacted third molars and outcomes following surgical removal of third molars., Results: Twelve published reviews were assessed. Major methodological problems in these include that authors did not describe review methods such as literature search strategy and criteria for inclusion of primary studies. Reviews with similar aims included different sets of primary studies as evidence. Details of primary studies quoted were seldom sufficient for readers to judge the reliability of the evidence. With the exception of two reviews with poorer quality, the reviews concluded that there is a lack of evidence to support the prophylactic removal of impacted third molars. Two decision analyses also concluded that, on average, patients' long-term wellbeing is maximised if extraction is confined to those impacted third molars with pathology., Conclusions: In the absence of good evidence to support prophylactic removal, there appears to be little justification for the removal of pathology-free impacted third molars.