How to maintain the maximal level of blinding in randomisation for a placebo-controlled drug trial

Survival Analysis and Cost Effectiveness of Silver Modified Atraumatic Restorative Treatment (SMART) and ART Occlusal Restorations in Primary Molars: a randomized controlled trial

OBJECTIVE

To evaluate and compare the clinical performance and cost effectiveness of Silver Modified Atraumatic Restorative Treatment (SMART) and Atraumatic Restorative Treatment (ART) restorations in primary molars over 12 months follow up period.

MATERIALS AND METHODS

Sixty-seven children, aged 5-9 years old having at least one asymptomatic primary molar with active caries, were randomly assigned to either the test arm (SMART) or the control arm (ART). Clinical performance was assessed after 6 and 12-months using the modified United States Public Health Services criteria. The trial was registered at Clinical Trial.gov with a registration number (NCT03881020). Treatment time for each restoration was recorded, Kaplan-Meier survival analysis and the log-rank test were performed (p<0.05) and cost effectiveness was measured at the end of the study.

RESULTS

Both techniques showed comparable clinical performance and the mean survival time was 11.8 and 11.6 months for SMART and ART restorations respectively with no detected significant differences (p=0.416). Mean treatment time for SMART restorations (7.8 min.), however, was significantly lower than ART (15 min.) (p < 0.001). SMART technique, also, showed statistically significant lower mean total cost per restoration (p <0.001).

CONCLUSIONS

Though SMART and ART have comparable clinical performance and survival in single-surface occlusal restorations in primary molars, SMART is less time consuming and more cost effective.

CLINICAL SIGNIFICANCE

Using SMART technique could change paradigms in caries management. Being a patient friendly and cost-effective approach, it could be adopted as a superior treatment option when dealing with young children, those with behavioral and medical challenges and for promoting access to oral care among the underprivileged.

Blinding in Clinical Trials: Seeing the Big Picture

Blinding mitigates several sources of bias which, if left unchecked, can quantitively affect study outcomes. Blinding remains under-utilized, particularly in non-pharmaceutical clinical trials, but is often highly feasible through simple measures. Although blinding is generally viewed as an effective method by which to eliminate bias, blinding does also pose some inherent limitations, and it behooves clinicians and researchers to be aware of such caveats. This article will review general principles for blinding in clinical trials, including examples of useful blinding techniques for both pharmaceutical and non-pharmaceutical trials, while also highlighting the limitations and potential consequences of blinding. Appropriate reporting on blinding in trial protocols and manuscripts, as well as future directions for blinding research, will also be discussed.

Who knew? The misleading specificity of "double-blind" and what to do about it

BACKGROUND

In randomized trials, the term "double-blind" (and its derivatives, single- and triple-blind, fully blind, and partially blind or masked) has no standard or widely accepted definition. Agreement about which groups are blinded is poor, and authors using these terms often do not identify which groups were blinded, despite specific reporting guidelines to the contrary. Nevertheless, many readers assume-incorrectly-that they know which groups are blinded. Thus, the term is ambiguous at best, misleading at worst, and, in either case, interferes with the accurate reporting, interpretation, and evaluation of randomized trials. The problems with the terms have been thoroughly documented in the literature, and many authors have recommended that they be abandoned.

PROPOSAL

We and our co-signers suggest eliminating the use of adjectives that modify "blinding" in randomized trials; a trial would be described as either blinded or unblinded. We also propose that authors report in a standard table which groups or individuals were blinded, what they were blinded to, how blinding was implemented, and whether blinding was maintained. Individuals with dual responsibilities, such as caregiving and data collecting, would also be identified. If blinding was compromised, authors should describe the potential implications of the loss of blinding on interpreting the results.

CONCLUSION

"Double blind" and its derivatives are terms with little to recommend their continued use. Eliminating the use of adjectives that impart a false specificity to the term would reduce misinterpretations, and recommending that authors report who was blinded to what and how in a standard table would require them to be specific about which groups and individuals were blinded.