Cluster Effects in a National Dental PBRN restorative study

Effectiveness of 38% Silver Diamine Fluoride in Reducing Dentine Hypersensitivity on Exposed Root Surface in Older Chinese Adults: Study Protocol for a Randomised Double-Blind Study

Background: Dentine hypersensitivity on an exposed root surface induces pain, affects daily oral hygiene practice, limits dietary choices and negatively affects quality of life. Silver diamine fluoride is marketed in the United States as a desensitising agent, but well-designed clinical trials are limited. This study evaluates the anti-hypersensitivity effect of silver diamine fluoride on hypersensitive teeth due to an exposed root surface in older Chinese adults. Methods/design: We will conduct a randomised double-blind clinical trial with a sample size of at least 148 Chinese older adults aged 65 or above who have dentine hypersensitivity due to an exposed root surface. We will collect written consent before the study. A trained examiner will examine the participants’ teeth with a blast of compressed air from a 3-in-1 syringe. Those adults who report a self-perceived sensitivity score (SS) (0 to 10) of 8 or more on at least one tooth with an exposed root surface will be recruited. The recruited older adults will be randomly allocated into two groups using a block randomisation of six. Group 1 participants will receive the application of 38% silver diamine fluoride solution every 4 weeks. Group 2 participants will receive the application of 5% potassium nitrate solution every 4 weeks. Dietary advice, oral hygiene instruction and fluoride toothpaste at 1450 ppm will be provided to participants in both groups. The same trained examiner will perform follow-up examinations for the participants and determine the dentine hypersensitivity in SS of the most hypersensitive tooth (with the highest pre-treatment SS) immediately after the intervention and at 4-week and 8-week intervals. Discussion: There is no consensus on the standard of care for a professionally applied desensitising agent in older adults. This trial will provide evidence for clinicians to devise an effective dental care plan for older adults with dentine hypersensitivity. Trial registration: NCT05392868 Registered on 22 May 2022.

Clinical evidence for professionally applied fluoride therapy to prevent and arrest dental caries in older adults: A systematic review

OBJECTIVE

To assess the clinical evidence for professionally applied fluoride therapy to prevent and arrest caries in older adults.

DATA/SOURCES

Two independent researchers searched the English literature published up to 31st Dec 2021 in five databases (PubMed, Scopus, the Cochrane Library, EMBASE, and Web of Science) for clinical trials with a comparison group on professionally applied fluoride therapy for caries prevention or arrest at older adults aged ≥60 years with any follow-up period. The outcomes were the mean difference in the number of new caries/caries-prevented fraction and caries arrest rate. The Cochrane guidelines were used for the risk of bias assessment.

STUDY SELECTION/RESULTS

Five hundred and twenty-seven studies were identified, and seven studies were finally included. Five studies were rated as having 'low risk'. The root caries-prevented fraction of 38% silver diamine fluoride (SDF) solution, 5% sodium fluoride (NaF) varnish, and 1.23% acidulated phosphate fluoride (APF) gel were 25-71%, 64%, and 32%, respectively. Meta-analysis indicated a decrease in the number of new root caries by 0.55 (95% CI: 0.32-0.78; p < 0.001) and an overall proportion of arrested root caries of 42% (95% CI: 33% to 49%; p < 0.001) after receiving 38% SDF application at the 24-month follow-up.

CONCLUSIONS

According to the findings, 5% NaF varnish and 1.23% APF gel prevented root caries, whereas 38% SDF solution prevented and arrested root caries in older adults. More well-designed clinical trials should be conducted to investigate various methods in caries prevention and arrest in older adults.

CLINICAL SIGNIFICANCE

Preventive measures effective in other age groups may not suit older adults, as caries type and associated risk factors vary. To date, no systematic review has evaluated professionally applied fluoride therapy in older adults. Evidence from clinical trials in older adults could aid clinical practice and public health measures. The International Prospective Register of Systematic Reviews (PROSPERO) registration number: CRD42022307025.

A road map for designing and reporting clinical trials in paediatric dentistry

BACKGROUND

Unless clinical trials are well-designed, there is a risk that they will not be usable to improve patient care.

AIM

This paper discusses some factors important in designing clinical trials in paediatric dentistry. It uses the prevention and management of dental caries in children as the lens through which to look at these.

FINDINGS

Amongst the factors to consider are clear research questions and objectives; appropriate outcomes and outcome measures; sample size calculation and the level of randomisation; methods for random allocation; and operator/assessor training. Experts in trial design including statisticians and a trialist should be consulted early in the design process. The aspects of trial design unique to cariology trials such as 'clustering' of data items, mixed dentition issues and those related to trials involving children (communication, consent etc) should be considered. Comprehensive reporting of trial results is essential.

CONCLUSION

There are many readily available resources and tools to help the researcher design a trial of good quality that will yield results useful to the research community and beyond, to those who will implement the findings and ultimately those who will benefit from them.

Factors affecting success rate of atraumatic restorative treatment (ART) restorations in children: A systematic review and meta-analysis

OBJECTIVES

Aim of this systematic review was to summarize the factors that affect the success rate of atraumatic restorative treatment (ART) restorations in children.

DATA/SOURCES

Two independent reviewers conducted a literature search in the databases PubMed, Medline and Web of Science until October 2019 with no initial time limit. Articles reporting on clinical outcomes of ART restorations placed in children were included.

STUDY SELECTION

A total of 67 articles were included in this review reporting on clinical outcomes of ART restorations placed in children in 47 studies. The overall estimated success rate and 95 % confidence interval (CI) of ART restorations were 0.71 (0.65-0.77) and 0.67 (0.56-0.78) at the 12-month and the 24-month follow-up, respectively. Operator was one of the significant factors associated with the success rate of ART restorations. ART restorations placed by dental students/therapists had a significantly lower success rate compared with those placed by dentists. Besides, type of restoration (single-surface vs. multiple-surface restoration) was also associated with the success rate of ART restorations. Other factors including dentition, restorative material, clinical setting, and moisture control method had no significant influence on the success rate of ART restorations in children.

CONCLUSION

It is concluded that ART approach can be used to manage cavitated caries lesions in children. Operator and type of restoration are significant factors influencing the success rate of ART restorations.

CLINICAL SIGNIFICANCE

This study provides valuable information on the factors that affect success rate of ART restorations in children, which helps clinicians to make informed decisions on provision of ART restorations in children.

A 24-month randomized controlled trial on the success rates of restoring untreated and SDF-treated dentine caries lesions in primary teeth with the ART approach

OBJECTIVE

To compare the success rates of restoring untreated and SDF-treated dentine caries lesions in primary teeth with atraumatic restorative treatment (ART) approach.

METHOD

Cavitated dentine caries lesions in preschool children were randomly allocated to two groups to be applied with either 38% silver diamine fluoride (SDF) solution or tonic water (control) ten weeks before being restored with the ART approach. Status of the restorations were assessed every six months by a blinded independent examiner. Multilevel logistic regression and multilevel survival analyses were conducted to assess the restoration success rates.

RESULTS

A total of 194 children (SDF group, 101; control group, 93) were included, with 260 and 249 ART restorations placed in the SDF and the control groups, respectively. At 24-month follow-up, 88 (87 %) and 84 (90 %) children remained in the SDF and the control groups, respectively. There was no significant difference between the ART restoration success rates of the two study groups (p > 0.05). The success rate of ART restorations was associated with the class of restorations. Class I restorations had the highest success rate (∼50 %), followed by Class V (∼35 %), Class II (∼15 %) and Class III (<10 %). Besides, the mean time used to place an ART restoration in a SDF-treated caries lesion was shorter than that in untreated lesion (4.8 vs. 5.1 min, p = 0.006).

CONCLUSION

Prior SDF application does not significantly affect the success rate of ART restorations placed in primary teeth. Besides, it is faster to place ART restorations in caries lesions that have been previously treated with SDF.

CLINICAL SIGNIFICANCE

Prior application of silver diamine fluoride solution on cavitated dentine caries lesions in primary teeth can shorten the average time required to place an ART restoration while not jeopardizing the success rate of the restorations.

Use of Data Analysis Methods in Dental Publications: Is There Evidence of a Methodological Change?

Objectives: To evaluate how data analysis methods in dental studies have changed in recent years. Methods: A total of 400 articles published in 2010 and 2017 in five dental journals, Journal of Dental Research, Caries Research, Community Dentistry and Oral Epidemiology, Journal of Dentistry, and Acta Odontologica Scandinavica, were analyzed. The study characteristics and the reporting of data analysis techniques were systematically identified. Results: The statistical intensity of the dental journals did not change from 2010 to 2017. Dental researchers did not adopt the data mining, machine learning, or Bayesian approaches advocated in the computer-oriented methodological literature. The determination of statistical significance was the most generally used method for conducting research in both 2010 and 2017. Observational study designs were more common in 2017. Insufficient and incomplete descriptions of statistical methods were still a serious problem. Conclusion: The stabilization of statistical intensity in the literature suggests that papers applying highly computationally complex data analysis methods have not meaningfully contributed to dental research or clinical care. Greater rigor is required in reporting the methods in dental research articles, given the current pervasiveness of failure to describe the basic techniques used.

Clustering effects of oral conditions based on clinical and radiographic examinations

OBJECTIVES

The intra-class correlation coefficient (ICC) is a measure of intra-subject clustering effects. A priori estimates of the ICC and the associated design effect (DE) are required for sample size estimation in clustered studies, and should be considered during their analysis, too. We aimed to determine the clustering effects of carious lesions, apical lesions, periodontal bone loss, and periodontal pocketing, assessed in clinical or radiographic examinations.

METHODS

A subsample of patients (n = 175) enrolled in the fifth German Oral Health Study provided data on clinically determined carious teeth (i.e., with untreated carious lesions, WHO method) as well as teeth with periodontal pocketing (i.e., with maximum probing-pocket-depths ≥ 4 mm). A sample of panoramic radiographs (n = 85) from randomly chosen patients, examined from 2010 to 2017 at the Charité dental hospital, provided data on radiographically determined carious teeth (i.e., with lesions extending into dentine or enamel), teeth with apical lesions (determined by dentists via majority vote), and teeth with periodontal bone loss (≥ 20% of root-length). The ICC and its 95% confidence interval (95% CI) were determined.

RESULTS

There were 3839 and 1961 teeth assessed in clinical and radiographic evaluations, respectively. For clinically or radiographically determined carious lesions, the ICC (95% CI) was 0.20 (0.16-0.24) or 0.19 (0.14-0.25), respectively. For clinical pocketing or radiographic bone loss, the ICC was 0.40 (0.35-0.46) or 0.30 (0.24-0.38), respectively. The lowest ICC was found for apical lesions at 0.08 (0.06-0.13).

CONCLUSIONS

The ICC varied between assessment methods and conditions. Clustered trials should account for this during study planning and data analysis.

CLINICAL RELEVANCE

Within the limitations of this study, and considering the risk of selection bias and the limited sample sizes of both datasets, clustering effects were substantial but varied between dental conditions. Studies not accounting for this during planning and analysis may yield misleading estimates if clustering is present.

The National Dental Practice-Based Research Network Adult Anterior Open Bite Study: Treatment recommendations and their association with patient and practitioner characteristics

INTRODUCTION

This aim of this paper is to describe and identify the practitioner and patient characteristics that are associated with treatment recommendations for adult anterior open bite patients across the United States.

METHODS

Practitioners and patients were recruited within the framework of the National Dental Practice-Based Research Network. Practitioners were asked about their demographic characteristics and their treatment recommendations for these patients. The practitioners also reported on their patients' dentofacial characteristics and provided initial cephalometric scans and intraoral photographs. Patients were asked about their demographic characteristics, previous orthodontic treatment, and goals for treatment. Four main treatment groups were evaluated: aligners, fixed appliances, temporary anchorage devices (TADs), and orthognathic surgery. Extractions were also investigated. Predictive multivariable models were created comparing various categories of treatment as well as extraction/nonextraction decisions.

RESULTS

Ninety-one practitioners (mostly orthodontists) and 347 patients were recruited from October 2015 to December 2016. Increased aligner recommendations were associated with white and Asian patients, the presence of tongue habits, and female practitioners. TADs were recommended more often in academic settings. Recommendations for orthognathic surgery were associated with demographic factors, such as availability of insurance coverage and practitioner race/ethnicity, and dentofacial characteristics, such as anteroposterior discrepancies, more severe open bites, and steeper mandibular plane angles. Extraction recommendations were largely associated with severe crowding and incisor proclination.

CONCLUSIONS

Both doctor and patient demographic factors, as well as dentofacial characteristics, were significantly associated with treatment recommendations for adult anterior open bite patients.

Recommended treatment of cracked teeth: Results from the National Dental Practice-Based Research Network

STATEMENT OF PROBLEM

Despite the high prevalence of posterior cracked teeth, questions remain regarding the best course of action for managing these teeth.

PURPOSE

The purpose of this clinical study was to identify and quantify the characteristics of visible cracks in posterior teeth and their association with treatment recommendations among patients in the National Dental Practice-Based Research Network.

MATERIAL AND METHODS

Network dentists enrolled patients with a single, vital posterior tooth with at least 1 observable external crack. Data were collected at the patient, tooth, and crack levels, including the presence and type of pain and treatment recommendations for subject teeth. Frequencies according to treatment recommendation were obtained, and odds ratios (ORs) comparing recommendations for the tooth to be restored versus monitored were calculated. Stepwise regressions were performed using generalized models to adjust for clustering; characteristics with P<.05 were retained.

RESULTS

A total of 209 dentists enrolled 2858 patients with a posterior tooth with at least 1 crack. Mean ±standard deviation patient age was 54 ±12 years; 1813 (63%) were female, 2394 (85%) were non-Hispanic white, 2213 (77%) had some dental insurance, and 2432 (86%) had some college education. Overall, 1297 (46%) teeth caused 1 or more of the following types of pain: 1055 sensitivity to cold, 459 biting, and 367 spontaneous. A total of 1040 teeth were recommended for 1 or more treatments: restoration (n=1018; 98%), endodontics (n=29; 3%), endodontic treatment and restoration (n=20; 2%), extraction (n=2; 0.2%), and noninvasive treatment, for example, occlusal device, desensitizing (n=11; 1%). The presence of caries (OR=67.3), biting pain (OR=7.3), and evidence of a crack on radiographs (OR=5.0) were associated with over 5-fold odds of recommending restoration. Spontaneous pain was associated with nearly 3-fold odds; pain to cold, having dental insurance, a crack that was detectable with an explorer or blocked transilluminated light, or connected with a restoration were each weakly associated with increased odds of recommending a restoration (OR<2.0).

CONCLUSIONS

Approximately one-third of cracked teeth were recommended for restoration. The presence of caries, biting pain, and evidence of a crack on a radiograph were strong predictors of recommending a restoration, although the evidence of a crack on a radiograph only accounted for a 3% absolute difference (4% recommended treatment versus 1% recommended monitoring).

Systematic review and simulation study of ignoring clustered data in surgical trials

BACKGROUND

Multiple surgical procedures in a single patient are relatively common and lead to dependent (clustered) data. This dependency needs to be accounted for in study design and data analysis. A systematic review was performed to assess how clustered data were handled in inguinal hernia trials. The impact of ignoring clustered data was estimated using simulations.

METHODS

PubMed, Embase and the Cochrane Library were reviewed systematically for RCTs published between 2004 and 2013, including patients undergoing unilateral or bilateral inguinal hernia repair. Study characteristics determining the appropriateness of handling clustered data were extracted. Using simulations, various statistical methods accounting for clustered data were compared with an analysis ignoring clustering by assuming 100 hernias, with a varying percentage of patients having bilateral hernias.

RESULTS

Of the 50 eligible trials including patients with bilateral hernias, 20 (40 per cent) did not provide information on how they dealt with clustered data and 18 (36 per cent) avoided clustering by assessing the outcome by patient and not by hernia. None of the remaining 12 trials (24 per cent) considered clustering in the design or analysis. In the simulations, ignoring clustering led to an increased type I error rate of up to 12 per cent and to a loss in power of up to 15 per cent, depending on whether the patient or the hernia was the randomization unit.

CONCLUSION

Clustering was rarely considered in inguinal hernia trials. The simulations underline the importance of considering clustering as part of the statistical analysis to avoid false-positive and false-negative results, and hence inappropriate study conclusions.

Comparison of practice based research network based quality improvement technical assistance and evaluation to other ongoing quality improvement efforts for changes in agency culture

BACKGROUND

Public health agencies in the USA are increasingly challenged to adopt Quality Improvement (QI) strategies to enhance performance. Many of the functional and structural barriers to effective use of QI can be found in the organizational culture of public health agencies. The purpose of this study was to assess the impact of public health practice based research network (PBRN) evaluation and technical assistance for QI interventions on the organizational culture of public health agencies in Georgia, USA.

METHODS

An online survey of key informants in Georgia's districts and county health departments was used to compare perceptions of characteristics of organizational QI culture between PBRN supported QI districts and non-PBRN supported districts before and after the QI interventions. The primary outcomes of concern were number and percentage of reported increases in characteristics of QI culture as measured by key informant responses to items assessing organizational QI practices from a validated instrument on QI Collaboratives. Survey results were analyzed using Multi-level Mixed Effects Logistic Model, which accounts for clustering/nesting.

RESULTS

Increases in QI organizational culture were consistent for all 10- items on a QI organizational culture survey related to: leadership support, use of data, on-going QI, and team collaboration. Statistically significant odds ratios were calculated for differences in increased QI organizational culture between PBRN-QI supported districts compared to Non-PBRN supported districts for 5 of the 10 items, after adjusting for District clustering of county health departments.

CONCLUSIONS

Agency culture, considered by many QI experts as the main goal of QI, is different than use of specific QI methods, such as Plan-Do-Study-Act (PDSA) cycles or root-cause analyses. The specific use of a QI method does not necessarily reflect culture change. Attempts to measure QI culture are newly emerging. This study documented significant improvements in characteristics of organizational culture and demonstrated the potential of PBRNs to support agency QI activities.

The CONSORT Statement: Application within and adaptations for orthodontic trials

High-quality randomized controlled trials (RCTs) are an integral part of evidence-based medicine. RCTs are the bricks and mortar of high-quality systematic reviews, which are important determinants of health care policy and clinical practice. For published research to be used most effectively, investigators and authors should follow the guidelines for accurate and transparent reporting of RCTs. The consolidated standards of reporting trials (CONSORT) statement and its extensions are among the most widely used reporting guidelines in biomedical research. CONSORT was adopted by the American Journal of Orthodontics and Dentofacial Orthopedics in 2004. Since 2011, this Journal has been actively implementing compliance with the CONSORT reporting guidelines. The objective of this explanatory article is to highlight the relevance and implications of the various CONSORT items to help authors to achieve CONSORT compliance in their research submissions of RCTs to this and other orthodontic journals.

The clustering effects of surfaces within the tooth and teeth within individuals

The objectives of this study were 1) to provide an estimate of the value of the intraclass correlation coefficient (ICC) for dental caries data at tooth and surface level, 2) to provide an estimate of the design effect (DE) to be used in the determination of sample size estimates for future dental surveys, and 3) to explore the usefulness of multilevel modeling of cross-sectional survey data by comparing the model estimates derived from multilevel and single-level models. Using data from the United Kingdom Adult Dental Health Survey 2009, the ICC and DE were calculated for surfaces within a tooth, teeth within the individual, and surfaces within the individual. Simple and multilevel logistic regression analysis was performed with the outcome variables carious tooth or surface. ICC estimated that 10% of the variance in surface caries is attributable to the individual level and 30% of the variance in surfaces caries is attributable to variation between teeth within individuals. When comparing multilevel with simple logistic models, β values were 4 to 5 times lower and the standard error 2 to 3 times lower in multilevel models. All the fit indices showed multilevel models were a better fit than simple models. The DE was 1.4 for the clustering of carious surfaces within teeth, 6.0 for carious teeth within an individual, and 38.0 for carious surfaces within the individual. The ICC for dental caries data was 0.21 (95% confidence interval [CI], 0.204-0.220) at the tooth level and 0.30 (95% CI, 0.284-0.305) at the surface level. The DE used for sample size calculation for future dental surveys will vary on the level of clustering, which is important in the analysis-the DE is greatest when exploring the clustering of surfaces within individuals. Failure to consider the effect of clustering on the design and analysis of epidemiological trials leads to an overestimation of the impact of interventions and the importance of risk factors in predicting caries outcome.