Evidence-based dentistry: Part IV. Research design and levels of evidence. The development of a consensus among primary care dentists of referral criteria for school dental screening Research utilization among dental hygienists in Sweden--a national survey. Immediate knowledge increase from an oral cancer information leaflet in patients attending a primary health care facility: a randomised controlled trial. Design of a community-based intergenerational oral health study: “Baby Smiles” A cluster randomised, controlled trial of the value of dental health educators in general dental practice A study of clinical questions in primary care. The FiCTION dental trial protocol – filling children’s teeth: indicated or not? Survey of oral care practices in US intensive care units. Evidence-based clinical practice guideline for the evaluation of potentially malignant disorders in the oral cavity: A report of the American Dental Association. The effect of motivational interviewing on oral healthcare knowledge, attitudes and behaviour of parents and caregivers of preschool children: an exploratory cluster randomised controlled study An oral cancer information leaflet for smokers in primary care: results from two randomised controlled trials. Delay and failure to publish dental research Access to dental care for children in the United States: a survey of general practitioners. General dental practitioners' views on the use of stainless steel crowns to restore primary molars Barriers to the treatment of childhood caries perceived by dentists working in different countries. Effect evaluation of an oral health promotion intervention in preschool children.
Previous papers in this series on evidence -based dentistry have discussed the first 2 steps in seeking answers to clinical problems formulating a clear question and strategically search ing for evidence . The next step , critical appraisal of the evidence , is made easier if one underst and s the basic concepts of clinical research design . The strongest design , especially for questions related to therapeutic or preventive interventions , is the r and omized , controlled trial . Questions relating to diagnosis , prognosis and causation are often studied with observational , rather than experimental , research design s. The strongest study design should be used whenever possible . Rules have been established to grade research evidence . This paper , the fourth in the series , presents an overview of research methodology most commonly used in the dental literature Objective To obtain consensus amongst a sample of primary care dentists in the North West of Engl and on a set of clinical criteria that should trigger referral following school dental screening . Design Delphi process . Setting Primary dental care , Engl and 2002 Method Primary care dentists in the North West of Engl and were r and omly selected to complete a two round ' Delphi exercise ' that included 10 potential referral criteria . The dentists were invited to express their level of support for the inclusion of each referral criterion . Main outcome measures Level of agreement for each referral criterion . Acceptance of any criterion was that the interquartile range should be no more than 3 scale points with the lower value being no less than 7 . Results Eighty-eight dentists , ( 72.7 % ) , completed the Delphi exercise . Six referral criteria met with the groups ' approval : Child with caries in permanent dentitionChild with darkened/discoloured permanent incisorsChild aged 9 - 10 years with overjet greater than 10 mmChild over six years with either gross plaque , calculus or swollen gumsChild with evidence of sepsisChild registered with a GDP with caries in permanent dentition . Conclusion It is possible for a representative sample of primary care dentists in the North West to agree referral criteria following school dental screening Over the last decade evidence -based practice has become increasingly important in health care as an approach to improve patient outcomes . It is vital that dental hygienists , like other health professionals , use research findings to inform clinical practice . The objective of the present study was to investigate the extent of research utilization among dental hygienists in Sweden and to investigate the relationship between level of education and factors related to research utilization . A r and om sample of 261 dental hygienists in Sweden , 113 with 1 year and 148 with 2-year education , responded to a postal question naire covering various aspects of research utilization , i.e. their attitudes towards research , availability and support for the implementation of research findings , use of research in daily practice , their activity in seeking new research findings and their participation in a range of research -related activities . Dental hygienists with 2-year education had a more positive attitude towards research , used research to a greater extent and were more active in seeking new research findings than dental hygienists with 1-year education . Overall , relatively few dental hygienists reported that they implemented research findings in practice ; the most frequently reported activity concerned reading research articles in professional journals . The conclusions are that the length of dental hygiene education is a key factor influencing the application of research findings to practice . One-year education appears to be inadequate to achieve evidence -based practice . Moreover , not even two years of formal education guarantees necessary competence in research for evidence -based dental hygiene practice The aim was to determine the immediate influence of a vali date d patient information leaflet ( PIL ) on oral cancer and knowledge in primary care attenders . Participants were patients ( n=800 ) attending their primary health care provider from 14 general practice s ( eight dental and six medical ) in the north west of Engl and . Measures were a previously vali date d knowledge question naire ( 36 dichotomous items ) , self-reported dental service attendance history and demographic variables . The results showed that patients who had read the oral cancer PIL demonstrated a significant increase in knowledge regardless of clinical setting ( F[1,739]=246.24 , P<0.0001 ) . Patients showed improvements in selecting the correct signs and risk factors associated with disease . Immediate knowledge gain from a simple PIL about oral cancer was found and independent of the primary care facility , where the PIL was distributed Background Rural , low-income pregnant women and their children are at high risk for poor oral health and have low utilization rates of dental care . The Baby Smiles study was design ed to increase low-income pregnant women ’s utilization of dental care , increase young children ’s dental care utilization , and improve home oral health care practice s. Methods / design Baby Smiles was a five-year , four-site r and omized intervention trial with a 2 × 2 factorial design . Four hundred participants were r and omly assigned to one of four treatment arms in which they received either brief Motivational Interviewing ( MI ) or health education ( HE ) delivered during pregnancy and after the baby was born . In the prenatal study phase , the interventions were design ed to encourage dental utilization during pregnancy . After childbirth , the focus was to utilize dental care for the infant by age one . The two primary outcome measures were dental utilization during pregnancy or up to two months postpartum for the mother , and preventive dental utilization by 18 months of age for the child . Medicaid cl aims data will be used to assess the primary outcomes . Question naires were administered at enrollment and 3 , 9 and 18 months postpartum ( study end ) to assess mediating and moderating factors . Discussion This trial can help define the most effective way to provide one-on-one counseling to pregnant women and new mothers regarding visits to the dentist during pregnancy and after the child is born . It supports previous work demonstrating the potential of reducing mother-to-child transmission of Streptococcus mutans and the initiation of dental caries prevention in early childhood . Trial registration Clinical Trials.gov Identifier Aim To test the effectiveness of dental health educators in general dental practice . Objective To evaluate the effectiveness and cost of primary care trusts seconding dental health educators free of charge to suitable general dental practice s to provide dental health counselling to mothers of regularly attending pre-school children at risk to caries . Method Two-cell , parallel group , cluster r and omised , controlled clinical trial of two years ' duration . Clinical setting : 30 general dental practice s in North-West Engl and . Participants : 269 mothers of 334 pre-school children . Interventions : Those in the test group were given visits to a dental health educator over a 2-year period to counsel mothers of at-risk , pre-school children . The rest were held as a control . Main outcome measures : Caries prevalence of the children and dental health knowledge , attitudes and toothbrushing skills of the parents . The full costs of the exercise were kept throughout . The statistical analysis controlled for the clustering of children within practice s. Results After 2 years , 271 ( 81 % ) children and 248 ( 92 % ) mothers remained in the study . There was an 18 % difference in mean dmft between the groups in favour of the test group children but this was not statistically significant . At the end of the study there was an 18 % difference in mean dmft between the groups in favour of the test group children but this was not statistically significant . No difference in plaque levels was found . The mothers in the test group were more knowledgeable , had better attitudes towards the dental health of their offspring and better toothbrushing skills than those in the control . Each 2-hour session to counsel ten parents cost £ 40 . Conclusion Primary care trusts should carefully consider the cost value of seconding dental health educators to counsel parents of regularly attending , at-risk , pre-school children when considering such an option This is a prospect i ve study of clinical questions generated in primary care consultations and a comparison of two approaches to answering those clinical questions . Twenty-one doctors in a university-based primary care clinic su bmi tted 78 clinical questions arising from patient consultations during 24 clinic days ( 0.01 question per patient encounter ) . These doctors subsequently found answers to 40 % of their questions but were satisfied with only 67 % of these answers . The investigators were able to provide answers for 95 % of the questions asked and the doctors rated these answers as satisfactory in 86 % of instances . Answers obtained by investigators had significantly higher satisfaction score than those obtained by doctors ' search ( p = 0.002 ) . The two main findings of this study are ( 1 ) almost all questions arising in clinic setting could be answered by intensive search ; ( 2 ) answers found by intensive search es were judged to be more satisfactory than those found routinely by doctors . Provision of an information retrieval service in addition to training in the search ing and appraisal of medical literature are possible solutions to the information needs of busy clinicians Background There is a lack of evidence for effective management of  dental caries ( decay ) in children ’s primary ( baby ) teeth and an apparent failure of conventional dental restorations ( fillings ) to prevent dental pain and infection for UK children in Primary Care . UK dental schools ’ teaching has been based on British Society of Paediatric Dentistry guidance which recommends that caries in primary teeth should be removed and a restoration placed . However , the evidence base for this is limited in volume and quality , and comes from studies conducted in either secondary care or specialist practice s. Restorations provided in specialist environments can be effective but the generalisability of this evidence to Primary Care has been question ed . The FiCTION trial addresses the Health Technology Assessment ( HTA ) Programme ’s commissioning brief and research question “ What is the clinical and cost effectiveness of restoration caries in primary teeth , compared to no treatment ? ” It compares conventional restorations with an intermediate treatment strategy based on the biological ( sealing-in ) management of caries and with no restorations . Methods / Design This is a Primary Care-based multi-centre , three-arm , parallel group , patient-r and omised controlled trial . Practitioners are recruiting 1461 children , ( 3–7 years ) with at least one primary molar tooth where caries extends into dentine . Children are r and omized and treated according to one of three treatment approaches ; conventional caries management with best practice prevention , biological management of caries with best practice prevention or best practice prevention alone . Baseline measures and outcome data ( at review /treatment during three year follow-up ) are assessed through direct reporting , clinical examination including blinded radiograph assessment , and child/parent question naires . The primary outcome measure is the incidence of either pain or infection related to dental caries . Secondary outcomes are ; incidence of caries in primary and permanent teeth , patient quality of life , cost-effectiveness , acceptability of treatment strategies to patients and parents and their experiences , and dentists ’ preferences . Discussion FiCTION will provide evidence for the most clinical ly-effective and cost-effective approach to managing caries in children ’s primary teeth in Primary Care . This will support general dental practitioners in treatment decision making for child patients to minimize pain and infection in primary teeth . The trial is currently recruiting patients .Trial registration Protocol ID : NCTU : IS RCT BACKGROUND Research has shown that oral care involving toothbrushes and topical antimicrobials improves the oral health of medically compromised patients and may reduce the incidence of nosocomial infections including pneumonia . This survey research was undertaken to determine the type and frequency of oral care in intensive care units ( ICUs ) in the United States and the attitudes , beliefs , and knowledge of health care workers . METHODS A r and omly selected survey of 102 ICUs within the continental United States participated with 556 respondents ; 97 % of respondents were registered nurses . MEASUREMENTS Frequency and type of oral care provided , attitudes and beliefs , and knowledge and training in oral care were measured . RESULTS Ninety-two percent of respondents perceived oral care to be a high priority . The primary methods of oral care involved the use of foam swabs , moisturizers , and mouthwash . Toothbrushes and toothpaste were used infrequently by almost 80 % of respondents . The majority of nurses indicated a need for research -proven oral care st and ards and desired to learn more . CONCLUSIONS In this r and om sample of ICUs , oral care methods were not consistent with current research and oral care protocol s. The translation of oral care research into practice in the ICU may improve the quality of care and decrease the incidence of ventilator-associated pneumonia BACKGROUND An expert panel convened by the American Dental Association ( ADA ) Council on Scientific Affairs and the Center for Evidence -Based Dentistry conducted a systematic review and formulated clinical recommendations to inform primary care clinicians about the potential use of adjuncts as triage tools for the evaluation of lesions , including potentially malignant disorders ( PMDs ) , in the oral cavity . TYPES OF STUDIES REVIEW ED This is an up date of the ADA 's 2010 recommendations on the early diagnosis of PMDs and oral squamous cell carcinoma . The authors conducted a systematic search of the literature in MEDLINE and Embase via Ovid and the Cochrane Central Register of Controlled Trials to identify r and omized controlled trials and diagnostic test accuracy studies . The authors used the Grading of Recommendations Assessment , Development and Evaluation approach to assess the certainty in the evidence and to move from the evidence to the decisions . RESULTS The panel formulated 1 good practice statement and 6 clinical recommendations that concluded that no available adjuncts demonstrated sufficient diagnostic test accuracy to support their routine use as triage tools during the evaluation of lesions in the oral cavity . For patients seeking care for suspicious lesions , immediate performance of a biopsy or referral to a specialist remains the single most important recommendation for clinical practice . In exceptional cases , when patients decline a biopsy or live in rural areas with limited access to care , the panel suggested that cytologic testing may be used to initiate the diagnostic process until a biopsy can be performed ( conditional recommendation , low- quality evidence ) . CONCLUSIONS AND PRACTICAL IMPLICATION S The authors urge clinicians to remain alert and take diligent action when they identify a PMD . The authors emphasize the need for counseling because patients may delay diagnosis because of anxiety and denial Background Motivational Interviewing ( MI ) has been used across primary healthcare and been shown to be effective in reducing the prevalence of early childhood caries ( ECC ) in preschool children . This study aim ed to compare the effect of MI , in contrast to traditional dental health education ( DHE ) , on oral health knowledge , attitudes , beliefs and behaviours among parents and caregivers of preschool children in Trinidad . Method The design of this exploratory study included a cluster r and omised controlled trial and semi-structured focus groups . Six preschools ( 79 parents and caregivers ) in Eastern Trinidad were r and omly assigned to a test or control group ( 3 preschools in each group ) . Parents and caregivers in the test-group ( n = 25 ) received a talk on dental health using an MI approach and the control-group ( n = 54 ) received a talk using traditional DHE . Both groups received additional , written dental health information . The MI group also received two telephone call follow-ups as part of the MI protocol . Both groups were given question naires before the talks and four months later . Question items included oral health knowledge , beliefs , attitudes , brushing behaviour , oral health self-efficacy , oral health fatalism and a specific instrument to asses ‘ readiness for change ’ , the Readiness Assessment of Parents Concerning Infant Dental Decay ( RAPIDD ) . Participants in the test-group were also invited to take part in a focus group to share their views on the dental health talk . Results At four month follow-up , knowledge items on fluoride use , tooth brushing , dietary practice and dental attendance increased in both the test ( DHE + MI ) and control ( DHE ) groups ( ( p < 0.05 , Chi Square test ) . In the test-group there were increases in mean child tooth brushing frequency and reduction in oral health fatalism ( p < 0.05 t-test ) . Findings from a thematic analysis of the focus group suggested that the MI talk and telephone follow-up were well accepted and helpful in supporting parent and caregiver efforts to improve oral health practice s for their preschool children . Conclusion In this exploratory controlled study there was some evidence that using an MI approach when delivering oral health information had a positive effect on parent/ caregiver oral health knowledge , attitudes and behaviours compared to traditional DHE . There is need for further research involving the use of brief-counselling techniques in this Caribbean population OBJECTIVES To investigate whether primary care patients who cl aim to smoke tobacco gain greater benefit of a patient information leaflet ( PIL ) on oral cancer than nonsmokers . METHODS Two studies were conducted . Study 1 examined the research question initially , and Study 2 acted as a replication and inclusion of additional secondary outcome measures . The leaflet was design ed and tested in an earlier study . Knowledge of oral cancer was assessed by a previously vali date d 36-dichotomous-item scale . A single-item question ascertained self-reported smoking status ( kappa = 0.94 ) . Study 1 participants were drawn from 14 practice s ( 6 medical , 8 dental ) . A r and omised control group design was adopted . The experimental group received the leaflet on attendance to the practice and then completed the question naire . The control group received the question naire only .  Complete data were collected from 739 respondents . The design of Study 2 was identical ; 786 new respondents from 16 practice s ( 7 medical , 9 dental ) were collected . RESULTS Both studies confirmed that smokers knew less about oral cancer than nonsmokers ( P < 0.05 ) when access to the leaflet had been denied . On receipt of the leaflet , there was no distinction in oral cancer knowledge between the smoking status categories of respondents . Evidence of reassurance about screening from leaflet exposure was supported by the second study . CONCLUSION This programmed research has demonstrated an effect of a brief PIL to offset the decrement in oral cancer knowledge observed in primary care patients who use tobacco in comparison to their nonsmoking counterparts . The leaflet reduced anxiety about oral health screening in smokers Objective To investigate the incidence and time taken to full publication of abstract s presented at dental scientific meetings . Design A retrospective observational study . Setting All abstract s from the 1993 proceedings of the European Orthodontic Society ( EOS ) and European Organisation for Caries Research ( ORCA ) and a 10 % r and om sample of abstract s from the International Association for Dental Research ( IADR ) conferences . Methods A cross-referenced Medline search of abstract title and authors was undertaken to determine whether abstract s had been published as full papers . Search es were censored 1 year prior to and 5 years post publication as an abstract . Publication rate was compared between abstract s presented orally and as posters . Main outcome measures Publication as a full paper and time taken to publication . Results 546 abstract s were investigated . 252 abstract s ( 46.1 % ) were found as full reports . Median time to publication of all abstract s was 18 months ( IQR 9 , 30 months ) . 99 of the oral abstract s ( 57 % ) and 153 ( 41 % ) of the poster abstract s were published . Relative Risk Oral vs Poster=1.37 CI ( 1.19 , 1.55 ) . Conclusion More than half of the research presented at EOS , IADR and ORCA in 1993 remained unpublished 5 years after presentation at the conference . Oral presentations were published more frequently than poster presentations BACKGROUND In response to concern that inadequate dental school training may create a barrier to access to care for children , the authors conducted a survey concerning general practitioners ' practice patterns involving child patients . METHODS The authors requested a list of 4,970 r and omly chosen general practitioners from the American Dental Association Survey Center . They then sent those dentists a written survey asking whether and in what numbers they treat children ; the ages and caries levels of any children they do treat ; their perceptions of their educational experiences in pediatric dentistry , and their perceived needs for continuing education in pediatric dentistry . They analyzed data using chi2 . RESULTS Ninety-one percent of the general dentists surveyed treated children , but those younger than 4 years of age , with high levels of caries , and whose care is funded by Medicaid were represented in very low numbers . The types of patients treated and procedures performed by the respondents were significantly ( P < or = .05 ) associated with the intensity of the respondents ' educational experiences , except for the number and types of Medicaid patients they treated . CONCLUSIONS These data indicate that the vast majority of general practitioners treat children in their practice s , but there still are groups of children for whom access to dental care is a problem . PRACTICE IMPLICATION S Very young children , children with high levels of caries and Medicaid-covered children have difficulty finding dental care in the general practice community Aim To ascertain general dental practitioners ' views on the use of stainless steel ( pre-formed metal ) crowns to restore carious primary molars . Method Ninety-three general dental practitioners were selected at r and om from those practising in Lancashire , Cheshire and Greater Manchester in 2003 and interviewed separately about the clinical care they provide to the primary dentition . Before the interview participants recorded the care they would provide for a case scenario , describing a child with a carious lesion that the British Society of Paediatric Dentistry ( BSPD ) guidelines indicate should be treated with a stainless steel crown . Results In answering the case scenario only six ( 7 % ) of the dentists reported that they would fit a stainless steel crown .  Of the 93 dentists interviewed 71 % knew of the BSPD guidelines , but only 18 % had ever fitted a stainless steel crown  in general practice . Reasons given for not using stainless steel crowns were they are inappropriate for many children , time consuming to fit , difficult to manipulate , expensive , and ugly . Conclusion The BSPD guidelines on the use of stainless steel crowns do not reflect the views of the majority of general dental practitioners who consider these crowns unsuitable for most children and an impractical restorative technique in busy daily practice OBJECTIVE To explore whether dentists ' beliefs and attitudes to providing preventive and restorative dental care for young children can form a barrier to the provision of care . BASIC RESEARCH DESIGN The  Barriers to  Childhood Caries  Treatment ( BaCCT ) Question naire , a st and ardised international measure was developed and applied . PARTICIPANTS Through a research consortium , each site was asked to recruit 100 dentists . The sample participating was not intended to be nationally representative . Dentists were mainly r and omly selected and contacted by mail with one or more mailings depending on site . RESULTS 2,333 dentists in 14 countries and 17 sites participated . Factor analysis identified four factors as potential barriers . Two factors were found to be barriers in many sites . First , in most countries , dentists agreed that young children 's coping skills limit their ability to accept dental care . Secondly , dentists with negative personal feelings , for example , that providing care can be stressful and troublesome and that they feel time constrained . Differences in dentists ' beliefs can be partly explained by their work profile , with those treating children often , and those working under systems where they feel they can provide quality care being least likely to identify barriers to providing care for children . CONCLUSIONS The BaCCT Question naire was determined to be a valid psychometric measure . Separately , it was found that health systems do impact on dentists ' ability to deliver preventive and restorative care for children but that these effects vary across countries and further work is needed to determine how best these should be examined OBJECTIVE This study evaluates the effectiveness of a multi-component oral health intervention in preschool children in a non-r and omized intervention study with a complementary baseline control . METHODS Participants in the main study were 2137 children born between October 2003 and July 2004 in Fl and ers , Belgium . In the intervention group ( 50.5 % of participants ) , an oral health education program was added to a st and ard preventive care program during the first 3 years of life .  Oral health examinations  were performed by trained dentists when the children were 3 ( 2007 ) and 5 ( 2009 ) years old . Data on dietary habits , oral hygiene habits and dental attendance were obtained through structured question naires . Regression analyses were applied to compare the results of the intervention and control group with baseline measurements obtained before the intervention ( 2003 ) in other cohorts of 3- ( N = 1291 ) and 5-year-olds ( N = 1325 ) living in the same regions . RESULTS The prevalence of caries experience was generally lower in the main study compared with the baseline cohorts , with little differences between the intervention and control group . For the oral health-related behaviours , the control group scored mostly better . Nevertheless , compared with baseline , limited differences were observed in dental attendance , tooth brushing , helping with tooth brushing and consuming in-between drinks ( P < 0.05 ) . CONCLUSION The study illustrates that a multi-component , theory-based intervention at community level had only a limited and temporary effect on oral health-related behaviours in the community under study . Further research is needed to determine how oral health in young children can be improved in the long term
Due to the low quality , small sample sizes or lack of adequate reporting of the outcome data , the evidence is inadequate to cl aim or refute a difference in postoperative sensitivity between different dental liners .
Since August 2009 , members of the Primary Care Dentistry Research Forum ( www.dentistry research .org ) have taken part in an online vote to identify questions in day-to-day practice that they felt most needed to be answered with conclusive research .