Similar Outcomes of Web-Based and Face-to-Face Training of the GRADE Approach for the Certainty of Evidence: Randomized Controlled Trial.

BACKGROUND: The GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach is a system for transparent evaluation of the certainty of evidence used in clinical practice guidelines and systematic reviews. GRADE is a key part of evidence-based medicine (EBM) training of health care professionals. OBJECTIVE: This study aimed to compare web-based and face-to-face methods of teaching the GRADE approach for evidence assessment. METHODS: A randomized controlled trial was conducted on 2 delivery modes of GRADE education integrated into a course on research methodology and EBM with third-year medical students. Education was based on the Cochrane Interactive Learning "Interpreting the findings" module, which had a duration of 90 minutes. The web-based group received the web-based asynchronous training, whereas the face-to-face group had an in-person seminar with a lecturer. The main outcome measure was the score on a 5-question test that assessed confidence interval interpretation and overall certainty of evidence, among others. Secondary outcomes included writing a recommendation for practice and course satisfaction. RESULTS: In all, 50 participants received the web-based intervention, and 47 participants received the face-to-face intervention. The groups did not differ in the overall scores for the Cochrane Interactive Learning test, with a median of 2 (95% CI 1.0-2.0) correct answers for the web-based group and 2 (95% CI 1.3-3.0) correct answers for the face-to-face group. Both groups gave the most correct answers to the question about rating a body of evidence (35/50, 70% and 24/47, 51% for the web-based and face-to-face group, respectively). The face-to-face group better answered the question about the overall certainty of evidence question. The understanding of the Summary of Findings table did not differ significantly between the groups, with a median of 3 correct answers to 4 questions for both groups (P=.352). The writing style for the recommendations for practice also did not differ between the 2 groups. Students' recommendations mostly reflected the strengths of the recommendations and focused on the target population, but they used passive words and rarely mentioned the setting for the recommendation. The language of the recommendations was mostly patient centered. Course satisfaction was high in both groups. CONCLUSIONS: Training in the GRADE approach could be equally effective when delivered asynchronously on the web or face-to-face. TRIAL REGISTRATION: Open Science Framework akpq7; https://osf.io/akpq7/.

Heterogeneity of outcomes in randomized controlled trials on implant prosthodontic therapy is hindering comparative effectiveness research: meta-research study.

BACKGROUND: Consistency in outcomes across clinical trials allows for comparing and combining results from different studies. A core outcome set (COS), representing a minimally agreed standardized group of outcomes that should be monitored and measured through research in a specific field of medicine, is not yet available for trials in implant prosthodontic (dental implant) therapy. This meta-research study aimed to analyze outcomes used in clinical trials on implant prosthodontic therapy. METHODS: We searched the Cochrane Oral Health Group (COHG) register to identify systematic reviews of interventions in implant prosthodontic therapy published by October 2023. From the randomized controlled trials (RCTs) included in the relevant reviews, we extracted data on the characteristics of the included trials and the outcomes used. We categorized outcomes into domains. RESULTS: From 182 systematic reviews in the COHG register, we included 11 systematic reviews on dental implant therapy. The reviews included 117 unique RCTs with 4725 participants, published from 1995 to 2020, which analyzed 74 different outcomes. Using different definitions, implant failure was analyzed in 73 RCTs. Seventeen RCTs did not define implant failure. Failure was most often (30 RCTs) followed up for one year. Only one RCT assessed implant failure after five years. Trials used 17 definitions of implant failure, while 17 trials did not report on the criteria of implant failure. Complications were analyzed in 48 RCTs, although they were not clearly defined in 12 RCTs. Failure of prosthodontic supra-structure was analyzed in 74 RCTs, with definitions of failure and criteria not clearly defined in 44 RCTs. Trials considered adverse events, peri-implant tissue health, patient attitudes, and other outcomes, including cost, aesthetics, or procedure duration. These outcomes were often different between trials. Twenty-six outcomes were used only once per study. CONCLUSIONS: Clinical trials in implant prosthodontics used different outcomes, different definitions of outcomes and used different times to monitor them. Standardization of outcomes is necessary to allow comparability and evidence synthesis about the effectiveness of implant prosthodontic therapy.

Publishing Identifiable Patient Photographs in Scientific Journals: Scoping Review of Policies and Practices.

BACKGROUND: Publishing identifiable patient data in scientific journals may jeopardize patient privacy and confidentiality if best ethical practices are not followed. Current journal practices show considerable diversity in the publication of identifiable patient photographs, and different stakeholders may have different opinions of and practices in publishing patient photographs. OBJECTIVE: This scoping review aimed to identify existing evidence and map knowledge gaps in medical research on the policies and practices of publishing identifiable photographs in scientific articles. METHODS: We performed a comprehensive search of the Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, CINAHL with Full Text, Database of Abstracts of Reviews of Effects, Ovid MEDLINE, and Scopus. The Open Science Framework, PROSPERO, BASE, Google Scholar, OpenGrey, ClinicalTrials.gov, the Campbell Collaboration Library, and Science.gov were also searched. RESULTS: After screening the initial 15,949 titles and abstracts, 98 (0.61%) publications were assessed for eligibility at the full-text level, and 30 (0.19%) publications were included in this review. The studies were published between 1994 and 2020; most had a cross-sectional design and were published in journals covering different medical disciplines. We identified 3 main topics. The first included ethical aspects of the use of facial photographs in publications. In different clinical settings, the consent process was not conducted properly, and health professionals did not recognize the importance of obtaining written patient consent for taking and using patient medical photographs. They often considered verbal consent sufficient or even used the photographs without consent. The second topic included studies that investigated the practices and use of medical photography in publishing. Both patients and doctors asked for confidential storage and maintenance of medical photographs. Patients preferred to be photographed by their physicians using an institutional camera and preferred nonidentifiable medical photographs not only for publication but also in general. Conventional methods of deidentification of facial photographs concealing the eye area were recognized as unsuccessful in protecting patient privacy. The third topic emerged from studies investigating medical photography in journal articles. These studies showed great diversity in publishing practices regarding consent for publication of medical photographs. Journal policies regarding the consent process and consent forms were insufficient, and existing ethical professional guidelines were not fully implemented in actual practices. Patients' photographs from open-access medical journals were found on public web-based platforms. CONCLUSIONS: This scoping review showed a diversity of practices in publishing identifiable patient photographs and an unsatisfactory level of knowledge of this issue among different stakeholders despite existing standards. Emerging issues include the availability of patients' photographs from open-access journals or preprints in the digital environment. There is a need to improve standards and processes to obtain proper consent to fully protect the privacy of patients in published articles.

Web-Based Educational Intervention to Improve Knowledge of Systematic Reviews Among Health Science Professionals: Randomized Controlled Trial.

BACKGROUND: Lack of knowledge of systematic reviews (SRs) could prevent individual health care professionals from using SRs as a source of information in their clinical practice or discourage them from participating in such research. OBJECTIVE: In this randomized controlled trial, we evaluated the effect of a short web-based educational intervention on short-term knowledge of SRs. METHODS: Eligible participants were 871 Master's students of university health sciences studies in Croatia; 589 (67.6%) students who agreed to participate in the trial were randomized using a computer program into 2 groups. Intervention group A (294/589, 49.9%) received a short web-based educational intervention about SR methodology, and intervention group B (295/589, 50.1%) was presented with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) checklist. The participants' knowledge of SRs was assessed before and after the intervention. The participants could not be blinded because of the nature of the intervention. The primary outcome was the difference in the percentage of correct answers about SR methodology per participant between the groups after the intervention, expressed as relative risk and 95% CI. RESULTS: Results from 162 and 165 participants in the educational intervention and PRISMA checklist groups, respectively, were available for analysis. Most of them (educational intervention group: 130/162, 80.2%; PRISMA checklist group: 131/165, 79.4%) were employed as health care professionals in addition to being health sciences students. After the intervention, the educational intervention group had 23% (relative risk percentage) more correct answers in the postintervention questionnaire than the PRISMA checklist group (relative risk=1.23, 95% CI 1.17-1.29). CONCLUSIONS: A short web-based educational intervention about SRs is an effective tool for short-term improvement of knowledge of SRs among health care studies students, most of whom were also employed as health care professionals. Further studies are needed to explore the long-term effects of the tested education. TRIAL REGISTRATION: OSF Registries 10.17605/OSF.IO/RYMVC; https://osf.io/rymvc.

Creating an online educational intervention to improve knowledge about systematic reviews among healthcare workers: mixed-methods pilot study.

BACKGROUND: Lack of knowledge about systematic reviews (SRs) could prevent individual healthcare workers (HCWs) from using SRs as a source of information in their clinical practice or discourage them from participating in such research. In this study, we aimed to explore in-depth the opinion of a sample of HCWs about the newly created online educational intervention designed to improve knowledge about SRs. METHODS: We created a brief online educational intervention on SRs, consisting of 11 textual modules. We evaluated it among practicing HCWs who graduated from a university-level health sciences program using a mixed-methods pilot study that consisted of pre- and post-intervention questionnaires and qualitative evaluation via semi-structured interviews. We assessed participants' knowledge about SR methodology before and after the intervention, and compared the responses. We sought their opinions about the characteristics of SRs. Also, the participants were presented with four scientific abstracts, where they were asked to distinguish whether those abstracts presented summaries of a systematic or a non-systematic review. RESULTS: Twelve participants took part in the study. In the pilot study, the participants' knowledge about SRs was improved after the intervention compared to the baseline. Participants provided positive feedback regarding the educational intervention. Suggestions to improve the educational intervention were to provide more details about the forest plot, add more digital content or images, provide more details about the methodological steps of an SR, add descriptions about practical applications of SRs and provide links to additional educational materials. The participants suggested that HCWs could be motivated to take part in such an education if it is offered as continuing medical education (CME) course or credit for academic/career advancement. CONCLUSION: HCWs provided positive feedback about the newly designed online educational intervention on SRs; they considered it an appropriate tool for learning about SRs and resulted in increased knowledge about SRs. In addition, participants gave suggestions for improving education, which can be used to tailor the education for end-users. In future studies, it would be useful to examine the effectiveness of the modified educational intervention on increasing knowledge in a larger sample and in the form of a randomized controlled trial.

Adequacy of risk of bias assessment in surgical vs non-surgical trials in Cochrane reviews: a methodological study.

BACKGROUND: Bias in randomized controlled trials (RCTs) can lead to underestimation or overestimation of the true effects of interventions. Surgical RCTs may suffer from the risk of bias (RoB) that is avoidable in trials of other interventions, and vice versa. We aimed to compare the adequacy of RoB assessments in surgical versus non-surgical RCTs included in Cochrane reviews and to assess the most common differences in those RoB assessments. Due to specificities of surgical trials, i.e. difficulties associated with blinding of surgical interventions, we hypothesized that assessments of surgical trials may be more adequate, compared to RCTs of non-surgical interventions. METHODS: This was a methodological study, analyzing methods of published Cochrane systematic reviews. Data were extracted from RoB tables in Cochrane reviews (judgments and accompanying explanatory comment) for the following four RoB domains used in the 2011 Cochrane RoB tool: randomization, allocation concealment, blinding of participants and personnel, and blinding of outcome assessors. We defined adequate assessments as those that were in line with instructions from the Cochrane Handbook for Systematic Reviews of Interventions. The prevalence of adequate assessments was compared in surgical versus non-surgical trials. The most common differences in both groups of reviews were presented. RESULTS: In 729 analyzed Cochrane reviews, there were 10,537 included trials. The prevalence of adequate RoB judgments made by Cochrane authors ranged from 87.9, 95%CI (87.3 to 88.6%) for randomization to 70.7, 95%CI (69.8 to 71.5%) for blinding of participants and personnel. For all analyzed RoB domains, the prevalence of adequate RoB domains was higher in surgical trials than in non-surgical trials. For two RoB domains assessing blinding, this difference between surgical and non-surgical trials was statistically significant (P < 0.001), while the difference was not significant for the RoB domain regarding randomization (P = 0.124) and allocation concealment (P = 0.039, ß < 0.8). CONCLUSIONS: RoB judgments were more in line with instructions from the Cochrane Handbook when Cochrane reviews assessed surgical trials, compared to those that analyzed non-surgical interventions. However, further steps are warranted to scrutinize RoB assessment in trials of both surgical and non-surgical interventions.

Risk of bias judgments for random sequence generation in Cochrane systematic reviews were frequently not in line with Cochrane Handbook.

BACKGROUND: Assessing the risk of bias (RoB) in included studies is one of the key methodological aspects of systematic reviews. Cochrane systematic reviews appraise RoB of randomised controlled trials (RCTs) with the Cochrane RoB tool. Detailed instructions for using the Cochrane RoB tool are provided in the Cochrane Handbook for Systematic Reviews of Interventions (The Cochrane Handbook). The purpose of this study was to analyse whether Cochrane authors use adequate judgments about the RoB for random sequence generation of RCTs included in Cochrane reviews. METHODS: We extracted authors' judgments (high, low or unclear RoB) and supports for judgments (comments accompanying judgments which explain the rationale for a judgment) for random sequence generation of included RCTs from RoB tables of Cochrane reviews using automated data scraping. We categorised all supporting comments, analysed the number and type of various supporting comments and assessed adequacy of RoB judgment for randomisation in line with recommendations from the Cochrane Handbook. RESULTS: We analysed 10,103 RCTs that were included in 704 Cochrane reviews. For 5,706 RCTs, randomisation was not described, but for the remaining RCTs, it was indicated that randomisation was performed using computer/software/internet (N = 2,850), random number table (N = 883), mechanical method (N = 359) or it was incomplete/inappropriate (N = 305). Overall, 1,220/10,103 trials (12%) did not have a RoB judgment in line with Cochrane Handbook guidance about randomisation. The highest proportion of misjudgements was found for trials with high RoB (28%), followed by those with low (20%) or unclear (3%). Therefore, one in eight judgments for the analysed domain in Cochrane reviews was not in line with Cochrane Handbook, and one in four if the judgment was "high risk". CONCLUSION: Authors of Cochrane reviews often make judgments about the RoB related to random sequence generation that are not in line with instructions given in the Cochrane Handbook, which compromises the reliability of the systematic reviews. Our results can help authors of both Cochrane and non-Cochrane reviews which use Cochrane RoB tool to avoid making common mistakes when assessing RoB in included trials.

The judgement of biases included in the category "other bias" in Cochrane systematic reviews of interventions: a systematic survey.

BACKGROUND: Clinical decisions are made based on Cochrane reviews, but the implementation of results of evidence syntheses such as Cochrane reviews is problematic if the evidence is not prepared consistently. All systematic reviews should assess the risk of bias (RoB) in included studies, and in Cochrane reviews, this is done by using Cochrane RoB tool. However, the tool is not necessarily applied according to the instructions. In this study, we aimed to determine the types of bias and their corresponding judgements noted in the 'other bias' domain of Cochrane RoB tool. METHODS: We analyzed Cochrane reviews that included randomized controlled trials (RCTs) and extracted data regarding 'other bias' from the RoB table and accompanying support for the judgment. We categorized different types of other bias. RESULTS: We analyzed 768 Cochrane reviews that included 11,369 RCTs. There were 602 (78%) Cochrane reviews that had 'other bias' domain in the RoB tool, and they included a total of 7811 RCTs. In the RoB table of 337 Cochrane reviews for at least one of the included trials it was indicated that no other bias was found and supporting explanations were inconsistently judged as low, unclear or high RoB. In the 524 Cochrane reviews that described various sources of other bias, there were 5762 individual types of explanations which we categorized into 31 groups. The judgments of the same supporting explanations were highly inconsistent. We found numerous other inconsistencies in reporting of sources of other bias in Cochrane reviews. CONCLUSION: Cochrane authors mention a wide range of sources of other bias in the RoB tool and they inconsistently judge the same supporting explanations. Inconsistency in appraising risk of other bias hinders reliability and comparability of Cochrane systematic reviews. Discrepant and erroneous judgments of bias in evidence synthesis may hinder implementation of evidence in routine clinical practice and reduce confidence in otherwise trustworthy sources of information. These results can help authors of Cochrane and non-Cochrane reviews to gain insight into various sources of other bias that can be found in trials, and also to help them avoid mistakes that were recognized in published Cochrane reviews.

Assessments of attrition bias in Cochrane systematic reviews are highly inconsistent and thus hindering trial comparability.

BACKGROUND: An important part of the systematic review methodology is appraisal of the risk of bias in included studies. Cochrane systematic reviews are considered golden standard regarding systematic review methodology, but Cochrane's instructions for assessing risk of attrition bias are vague, which may lead to inconsistencies in authors' assessments. The aim of this study was to analyze consistency of judgments and support for judgments of attrition bias in Cochrane reviews of interventions published in the Cochrane Database of Systematic Reviews (CDSR). METHODS: We analyzed Cochrane reviews published from July 2015 to June 2016 in the CDSR. We extracted data on number of included trials, judgment of attrition risk of bias for each included trial (low, unclear or high) and accompanying support for the judgment (supporting explanation). We also assessed how many Cochrane reviews had different judgments for the same supporting explanations. RESULTS: In the main analysis we included 10,292 judgments and supporting explanations for attrition bias from 729 Cochrane reviews. We categorized supporting explanations for those judgments into four categories and we found that most of the supporting explanations were unclear. Numerical indicators for percent of attrition, as well as statistics related to attrition were judged very differently. One third of Cochrane review authors had more than one category of supporting explanation; some had up to four different categories. Inconsistencies were found even with the number of judgments, names of risk of bias domains and different judgments for the same supporting explanations in the same Cochrane review. CONCLUSION: We found very high inconsistency in methods of appraising risk of attrition bias in recent Cochrane reviews. Systematic review authors need clear guidance about different categories they should assess and judgments for those explanations. Clear instructions about appraising risk of attrition bias will improve reliability of the Cochrane's risk of bias tool, help authors in making decisions about risk of bias and help in making reliable decisions in healthcare.

Home use of interdental cleaning devices, in addition to toothbrushing, for preventing and controlling periodontal diseases and dental caries.

BACKGROUND: Dental caries (tooth decay) and periodontal diseases (gingivitis and periodontitis) affect the majority of people worldwide, and treatment costs place a significant burden on health services. Decay and gum disease can cause pain, eating and speaking difficulties, low self-esteem, and even tooth loss and the need for surgery. As dental plaque is the primary cause, self-administered daily mechanical disruption and removal of plaque is important for oral health. Toothbrushing can remove supragingival plaque on the facial and lingual/palatal surfaces, but special devices (such as floss, brushes, sticks, and irrigators) are often recommended to reach into the interdental area. OBJECTIVES: To evaluate the effectiveness of interdental cleaning devices used at home, in addition to toothbrushing, compared with toothbrushing alone, for preventing and controlling periodontal diseases, caries, and plaque. A secondary objective was to compare different interdental cleaning devices with each other. SEARCH METHODS: Cochrane Oral Health's Information Specialist searched: Cochrane Oral Health's Trials Register (to 16 January 2019), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2018, Issue 12), MEDLINE Ovid (1946 to 16 January 2019), Embase Ovid (1980 to 16 January 2019) and CINAHL EBSCO (1937 to 16 January 2019). The US National Institutes of Health Trials Registry (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication. SELECTION CRITERIA: Randomised controlled trials (RCTs) that compared toothbrushing and a home-use interdental cleaning device versus toothbrushing alone or with another device (minimum duration four weeks). DATA COLLECTION AND ANALYSIS: At least two review authors independently screened searches, selected studies, extracted data, assessed studies' risk of bias, and assessed evidence certainty as high, moderate, low or very low, according to GRADE. We extracted indices measured on interproximal surfaces, where possible. We conducted random-effects meta-analyses, using mean differences (MDs) or standardised mean differences (SMDs). MAIN RESULTS: We included 35 RCTs (3929 randomised adult participants). Studies were at high risk of performance bias as blinding of participants was not possible. Only two studies were otherwise at low risk of bias. Many participants had a low level of baseline gingival inflammation.Studies evaluated the following devices plus toothbrushing versus toothbrushing: floss (15 trials), interdental brushes (2 trials), wooden cleaning sticks (2 trials), rubber/elastomeric cleaning sticks (2 trials), oral irrigators (5 trials). Four devices were compared with floss: interdental brushes (9 trials), wooden cleaning sticks (3 trials), rubber/elastomeric cleaning sticks (9 trials) and oral irrigators (2 trials). Another comparison was rubber/elastomeric cleaning sticks versus interdental brushes (3 trials).No trials assessed interproximal caries, and most did not assess periodontitis. Gingivitis was measured by indices (most commonly, Löe-Silness, 0 to 3 scale) and by proportion of bleeding sites. Plaque was measured by indices, most often Quigley-Hein (0 to 5). PRIMARY OBJECTIVE: comparisons against toothbrushing aloneLow-certainty evidence suggested that flossing, in addition to toothbrushing, may reduce gingivitis (measured by gingival index (GI)) at one month (SMD -0.58, 95% confidence interval (CI) -1.12 to -0.04; 8 trials, 585 participants), three months or six months. The results for proportion of bleeding sites and plaque were inconsistent (very low-certainty evidence).Very low-certainty evidence suggested that using an interdental brush, plus toothbrushing, may reduce gingivitis (measured by GI) at one month (MD -0.53, 95% CI -0.83 to -0.23; 1 trial, 62 participants), though there was no clear difference in bleeding sites (MD -0.05, 95% CI -0.13 to 0.03; 1 trial, 31 participants). Low-certainty evidence suggested interdental brushes may reduce plaque more than toothbrushing alone (SMD -1.07, 95% CI -1.51 to -0.63; 2 trials, 93 participants).Very low-certainty evidence suggested that using wooden cleaning sticks, plus toothbrushing, may reduce bleeding sites at three months (MD -0.25, 95% CI -0.37 to -0.13; 1 trial, 24 participants), but not plaque (MD -0.03, 95% CI -0.13 to 0.07).Very low-certainty evidence suggested that using rubber/elastomeric interdental cleaning sticks, plus toothbrushing, may reduce plaque at one month (MD -0.22, 95% CI -0.41 to -0.03), but this was not found for gingivitis (GI MD -0.01, 95% CI -0.19 to 0.21; 1 trial, 12 participants; bleeding MD 0.07, 95% CI -0.15 to 0.01; 1 trial, 30 participants).Very-low certainty evidence suggested oral irrigators may reduce gingivitis measured by GI at one month (SMD -0.48, 95% CI -0.89 to -0.06; 4 trials, 380 participants), but not at three or six months. Low-certainty evidence suggested that oral irrigators did not reduce bleeding sites at one month (MD -0.00, 95% CI -0.07 to 0.06; 2 trials, 126 participants) or three months, or plaque at one month (SMD -0.16, 95% CI -0.41 to 0.10; 3 trials, 235 participants), three months or six months, more than toothbrushing alone. SECONDARY OBJECTIVE: comparisons between devicesLow-certainty evidence suggested interdental brushes may reduce gingivitis more than floss at one and three months, but did not show a difference for periodontitis measured by probing pocket depth. Evidence for plaque was inconsistent.Low- to very low-certainty evidence suggested oral irrigation may reduce gingivitis at one month compared to flossing, but very low-certainty evidence did not suggest a difference between devices for plaque.Very low-certainty evidence for interdental brushes or flossing versus interdental cleaning sticks did not demonstrate superiority of either intervention.Adverse eventsStudies that measured adverse events found no severe events caused by devices, and no evidence of differences between study groups in minor effects such as gingival irritation. AUTHORS' CONCLUSIONS: Using floss or interdental brushes in addition to toothbrushing may reduce gingivitis or plaque, or both, more than toothbrushing alone. Interdental brushes may be more effective than floss. Available evidence for tooth cleaning sticks and oral irrigators is limited and inconsistent. Outcomes were mostly measured in the short term and participants in most studies had a low level of baseline gingival inflammation. Overall, the evidence was low to very low-certainty, and the effect sizes observed may not be clinically important. Future trials should report participant periodontal status according to the new periodontal diseases classification, and last long enough to measure interproximal caries and periodontitis.

WITHDRAWN: Interdental brushing for the prevention and control of periodontal diseases and dental caries in adults.

BACKGROUND: Effective oral hygiene is a crucial factor in maintaining good oral health, which is associated with overall health and health-related quality of life. Dental floss has been used for many years in conjunction with toothbrushing for removing dental plaque in between teeth, however, interdental brushes have been developed which many people find easier to use than floss, providing there is sufficient space between the teeth. OBJECTIVES: To evaluate the effects of interdental brushing in addition to toothbrushing, as compared with toothbrushing alone or toothbrushing and flossing for the prevention and control of periodontal diseases, dental plaque and dental caries. SEARCH METHODS: We searched the following electronic databases: the Cochrane Oral Health Group's Trials Register (to 7 March 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 2), MEDLINE via OVID (1946 to 7 March 2013), EMBASE via OVID (1980 to 7 March 2013), CINAHL via EBSCO (1980 to 7 March 2013), LILACS via BIREME (1982 to 7 March 2013), ZETOC Conference Proceedings (1980 to 7 March 2013) and Web of Science Conference Proceedings (1990 to 7 March 2013). We searched the US National Institutes of Health Trials Register (http://clinicaltrials.gov) and the metaRegister of Controlled Trials (http://www.controlled-trials.com/mrct/) for ongoing trials to 7 March 2013. No restrictions were placed on the language or date of publication when searching the electronic databases. SELECTION CRITERIA: We included randomised controlled trials (including split-mouth design, cross-over and cluster-randomised trials) of dentate adult patients. The interventions were a combination of toothbrushing and any interdental brushing procedure compared with toothbrushing only or toothbrushing and flossing. DATA COLLECTION AND ANALYSIS: At least two review authors assessed each of the included studies to confirm eligibility, assessed risk of bias and extracted data using a piloted data extraction form. We calculated standardised mean difference (SMD) and 95% confidence interval (CI) for continuous outcomes where different scales were used to assess an outcome. We attempted to extract data on adverse effects of interventions. Where data were missing or unclear we attempted to contact study authors to obtain further information. MAIN RESULTS: There were seven studies (total 354 participants analysed) included in this review. We assessed one study as being low, three studies as being high and three studies as being at unclear risk of bias. Studies only reported the clinical outcome gingivitis and plaque data, with no studies providing data on many of the outcomes: periodontitis, caries, halitosis and quality of life. Three studies reported that no adverse events were observed or reported during the study. Two other studies provided some data on adverse events but we were unable to pool the data due to lack of detail. Two studies did not report whether adverse events occurred.Interdental brushing in addition to toothbrushing, as compared with toothbrushing aloneOnly one high risk of bias study (62 participants in analysis) looked at this comparison and there was very low-quality evidence for a reduction in gingivitis (0 to 4 scale, mean in control): mean difference (MD) 0.53 (95% CI 0.23 to 0.83) and plaque (0 to 5 scale): MD 0.95 (95% CI 0.56 to 1.34) at one month, favouring of use of interdental brushes. This represents a 34% reduction in gingivitis and a 32% reduction in plaque.Interdental brushing in addition to toothbrushing, as compared with toothbrushing and flossingSeven studies provided data showing a reduction in gingivitis in favour of interdental brushing at one month: SMD -0.53 (95% CI -0.81 to -0.24, seven studies, 326 participants, low-quality evidence). This translates to a 52% reduction in gingivitis (Eastman Bleeding Index). Although a high effect size in the same direction was observed at three months (SMD -1.98, 95% CI -5.42 to 1.47, two studies, 107 participants, very low quality), the confidence interval was wide and did not exclude the possibility of no difference. There was insufficient evidence to claim a benefit for either interdental brushing or flossing for reducing plaque (SMD at one month 0.10, 95% CI -0.13 to 0.33, seven studies, 326 participants, low-quality evidence) and insufficient evidence at three months (SMD -2.14, 95% CI -5.25 to 0.97, two studies, 107 participants very low-quality evidence). AUTHORS' CONCLUSIONS: Only one study looked at whether toothbrushing with interdental brushing was better than toothbrushing alone, and there was very low-quality evidence for a reduction in gingivitis and plaque at one month. There is also low-quality evidence from seven studies that interdental brushing reduces gingivitis when compared with flossing, but these results were only found at one month. There was insufficient evidence to determine whether interdental brushing reduced or increased levels of plaque when compared to flossing.

WITHDRAWN: Flossing for the management of periodontal diseases and dental caries in adults.

BACKGROUND: Good oral hygiene is thought to be important for oral health. This review is to determine the effectiveness of flossing in addition to toothbrushing for preventing gum disease and dental caries in adults. OBJECTIVES: To assess the effects of flossing in addition to toothbrushing, as compared with toothbrushing alone, in the management of periodontal diseases and dental caries in adults. SEARCH METHODS: We searched the following electronic databases: the Cochrane Oral Health Group Trials Register (to 17 October 2011), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 4), MEDLINE via OVID (1950 to 17 October 2011), EMBASE via OVID (1980 to 17 October 2011), CINAHL via EBSCO (1980 to 17 October 2011), LILACS via BIREME (1982 to 17 October 2011), ZETOC Conference Proceedings (1980 to 17 October 2011), Web of Science Conference Proceedings (1990 to 17 October 2011), Clinicaltrials.gov (to 17 October 2011) and the metaRegister of Controlled Clinical Trials (to 17 October 2011). We imposed no restrictions regarding language or date of publication. We contacted manufacturers of dental floss to identify trials. SELECTION CRITERIA: We included randomised controlled trials conducted comparing toothbrushing and flossing with only toothbrushing, in adults. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed risk of bias for the included studies and extracted data. We contacted trial authors for further details where these were unclear. The effect measure for each meta-analysis was the standardised mean difference (SMD) with 95% confidence intervals (CI) using random-effects models. We examined potential sources of heterogeneity, along with sensitivity analyses omitting trials at high risk of bias. MAIN RESULTS: Twelve trials were included in this review, with a total of 582 participants in flossing plus toothbrushing (intervention) groups and 501 participants in toothbrushing (control) groups. All included trials reported the outcomes of plaque and gingivitis. Seven of the included trials were assessed as at unclear risk of bias and five were at high risk of bias.Flossing plus toothbrushing showed a statistically significant benefit compared to toothbrushing in reducing gingivitis at the three time points studied, the SMD being -0.36 (95% CI -0.66 to -0.05) at 1 month, SMD -0.41 (95% CI -0.68 to -0.14) at 3 months and SMD -0.72 (95% CI -1.09 to -0.35) at 6 months. The 1-month estimate translates to a 0.13 point reduction on a 0 to 3 point scale for Loe-Silness gingivitis index, and the 3 and 6 month results translate to 0.20 and 0.09 reductions on the same scale.Overall there is weak, very unreliable evidence which suggests that flossing plus toothbrushing may be associated with a small reduction in plaque at 1 or 3 months.None of the included trials reported data for the outcomes of caries, calculus, clinical attachment loss, or quality of life. There was some inconsistent reporting of adverse effects. AUTHORS' CONCLUSIONS: There is some evidence from twelve studies that flossing in addition to toothbrushing reduces gingivitis compared to toothbrushing alone. There is weak, very unreliable evidence from 10 studies that flossing plus toothbrushing may be associated with a small reduction in plaque at 1 and 3 months. No studies reported the effectiveness of flossing plus toothbrushing for preventing dental caries.

Knowledge and attitudes about sports-related dental injuries and mouthguard use in young athletes in four different contact sports-water polo, karate, taekwondo and handball.

BACKGROUND/AIMS: The increasing popularity of participating in sports activities among children and adolescents has increased the risk of sports-related orofacial and dental injuries. Therefore, it is important to establish efficient preventive strategies regarding sports-related dental trauma. The aim of this study was to evaluate the occurrence of sports-related dental injuries in young athletes and to compare the frequency of such injuries between high-risk and medium-risk sports, along with assessing athletes' attitudes and habits regarding mouthguard use. METHODS: A total of 229 young athletes from four different sports (water polo (n = 59), karate (n = 58), taekwondo (n = 57) and handball (n = 55)) participated in this study. A standardized questionnaire about the frequency of orofacial and dental injuries was used. Questions were also asked about athletes' habits related to mouthguard use. RESULTS: Mean age of the participants was 12.9 ± 3.2 years, and the average time of playing experience was 4.8 ± 3.1 years. Orofacial injury had been experienced by 58 athletes (25.3%), while 31 athletes (13.5%) suffered dental injury. Higher rate of dental injuries was observed in water polo (18.6%), karate (17.2%) and handball (21.8%) than in taekwondo (3.5%) (P = .035). Most participants were aware of mouthguards for dental trauma prevention and considered them efficient for preventing dental injuries during sports activities, but only 94 (41%) used them. There was a statistically significant difference in the use of mouthguards between taekwondo (73.7%) and karate (70.7%) players compared to handball (14.5%) and water polo players (5.1%) (P < .001). CONCLUSIONS: Handball and water polo had similarly high occurrence of dental trauma as karate, a high-risk martial art sport. Therefore, the classification of sports according to the risk of dental trauma should be reconsidered. It would be beneficial to make wearing a mouthguard mandatory in all high-risk sports, as well as in those with medium-risk for dental injuries.

Methodological and Reporting Quality of Systematic Reviews Published in the Highest Ranking Journals in the Field of Pain.

BACKGROUND: Systematic reviews (SRs) are important for making clinical recommendations and guidelines. We analyzed methodological and reporting quality of pain-related SRs published in the top-ranking anesthesiology journals. METHODS: This was a cross-sectional meta-epidemiological study. SRs published from 2005 to 2015 in the first quartile journals within the Journal Citation Reports category Anesthesiology were analyzed based on the Journal Citation Reports impact factor for year 2014. Each SR was assessed by 2 independent authors using Assessment of Multiple Systematic Reviews (AMSTAR) and Preferred Reporting Items of Systematic reviews and Meta-Analyses (PRISMA) tools. Total score (median and interquartile range, IQR) on checklists, temporal trends in total score, correlation in total scores between the 2 checklists, and variability of those results between journals were analyzed. RESULTS: A total of 446 SRs were included. Median total score of AMSTAR was 6/11 (IQR: 4-7) and of PRISMA 18.5/27 (IQR: 15-22). High compliance (reported in over 90% SRs) was found in only 1 of 11 AMSTAR and 5 of 27 PRISMA items. Low compliance was found for the majority of AMSTAR and PRISMA individual items. Linear regression indicated that there was no improvement in the methodological and reporting quality of SRs before and after the publication of the 2 checklists (AMSTAR: F(1,8) = 0.22; P = .65, PRISMA: F(1,7) = 0.22; P = .47). Total scores of AMSTAR and PRISMA had positive association (R = 0.71; P < .0001). CONCLUSIONS: Endorsement of PRISMA in instructions for authors was not a guarantee of compliance. Methodological and reporting quality of pain-related SRs should be improved using relevant checklists. This can be remedied by a joint effort of authors, editors, and peer reviewers.

The Influence of Contemporary Denture Base Fabrication Methods on Residual Monomer Content, Flexural Strength and Microhardness.

(1) Background: Digital technologies are available for denture base fabrication, but there is a lack of scientific data on the mechanical and chemical properties of the materials produced in this way. Therefore, the aim of this study was to investigate the residual monomer content, flexural strength and microhardness of denture base materials as well as correlations between investigated parameters. (2) Methods: Seven denture base materials were used: one conventional heat cured polymethyl methacrylate, one polyamide, three subtractive manufactured materials and two additive manufactured materials. High-performance liquid chromatography was used to determine residual monomer content and the test was carried out in accordance with the specification ISO No. 20795-1:2013. Flexural strength was also determined according to the specification ISO No. 20795-1:2013. The Vickers method was used to investigate microhardness. A one-way ANOVA with a Bonferroni post-hoc test was used for the statistical analysis. The Pearson correlation test was used for the correlation analysis. (3) Results: There was a statistically significant difference between the values of residual monomer content of the different denture base materials (p < 0.05). Anaxdent pink blank showed the highest value of 3.2% mass fraction, while Polident pink CAD-CAM showed the lowest value of 0.05% mass fraction. The difference between the flexural strength values of the different denture base materials was statistically significant (p < 0.05), with values ranging from 62.57 megapascals (MPa) to 103.33 MPa. The difference between the microhardness values for the different denture base materials was statistically significant (p < 0.05), and the values obtained ranged from 10.61 to 22.86 Vickers hardness number (VHN). A correlation was found between some results for the material properties investigated (p < 0.05). (4) Conclusions: The selection of contemporary digital denture base manufacturing techniques may affect residual monomer content, flexural strength and microhardness but is not the only criterion for achieving favourable properties.

Adherence to the Guideline for Reporting Evidence-based practice Educational interventions and Teaching (GREET) of studies on evidence-based healthcare e-learning: a cross-sectional study.

OBJECTIVES: The objectives of this study are to assess reporting of evidence-based healthcare (EBHC) e-learning interventions using the Guideline for Reporting Evidence-based practice Educational interventions and Teaching (GREET) checklist and explore factors associated with compliant reporting. DESIGN: Methodological cross-sectional study. METHODS: Based on the criteria used in an earlier systematic review, we included studies comparing EBHC e-learning and any other form of EBHC training or no EBHC training. We searched Medline, Embase, ERIC, CINAHL, CENTRAL, SCOPUS, Web of Knowledge, PsycInfo, ProQuest and Best Evidence Medical Education up to 4 January 2023. Screening of titles, abstracts, full-text articles and data extraction was done independently by two authors. For each study, we assessed adherence to each of the 17 GREET items and extracted information on possible predictors. Adequacy of reporting for each item of the GREET checklist was judged with yes (provided complete information), no (provided no information), unclear (when insufficient information was provided), or not applicable, when the item was clearly of no relevance to the intervention described (such as for item 8-details about the instructors-in the studies which used electronic, self-paced intervention, without any tutoring). Studies' adherence to the GREET checklist was presented as percentages and absolute numbers. We performed univariate analysis to assess the association of potential adherence predictors with the GREET checklist. We summarised results descriptively. RESULTS: We included 40 studies, the majority of which assessed e-learning or blended learning and mostly involved medical and other healthcare students. None of the studies fully reported all the GREET items. Overall, the median number of GREET items met (received yes) per study was 8 and third quartile (Q3) of GREET items met per study was 9 (min. 4 max. 14). When we used Q3 of the number of items met as cut-off point, adherence to the GREET reporting checklist was poor with 7 out of 40 studies (17.5%) reporting items of the checklist on acceptable level (adhered to at least 10 items out of 17). None of the studies reported on all 17 GREET items. For 3 items, 80% of included studies well reported information (received yes for these items): item 1 (brief description of intervention), item 4 (evidence-based practice content) and item 6 (educational strategies). Items for which 50% of included studies reported complete information (received yes for these items) included: item 9 (modes of delivery), item 11 (schedule) and 12 (time spent on learning). The items for which 70% or more of included studies did not provide information (received no for these items) included: item 7 (incentives) and item 13 (adaptations; for both items 70% of studies received no for them), item 14 (modifications of educational interventions-95% of studies received no for this item), item 16 (any processes to determine whether the materials and the educational strategies used in the educational intervention were delivered as originally planned-93% of studies received no for this item) and 17 (intervention delivery according to schedule-100% of studies received no for this item). Studies published after September 2016 showed slight improvements in nine reporting items. In the logistic regression models, using the cut-off point of Q3 (10 points or above) the odds of acceptable adherence to GREET guidelines were 7.5 times higher if adherence to other guideline (Consolidated Standards of Reporting Trials, Strengthening the Reporting of Observational Studies in Epidemiology, etc) was reported for a given study type (p=0.039), also higher number of study authors increased the odds of adherence to GREET guidance by 18% (p=0.037). CONCLUSIONS: Studies assessing educational interventions on EBHC e-learning still poorly adhere to the GREET checklist. Using other reporting guidelines increased the odds of better GREET reporting. Journals should call for the use of appropriate use of reporting guidelines of future studies on teaching EBHC to increase transparency of reporting, decrease unnecessary research duplication and facilitate uptake of research evidence or result. STUDY REGISTRATION NUMBER: The Open Science Framework (https://doi.org/10.17605/OSF.IO/V86FR).

Education of adult type 1 diabetes patients in a diabetes ward setting: a best practice implementation project.

INTRODUCTION AND OBJECTIVES: Type 1 diabetes is an autoimmune disease that destroys insulin-producing cells in the pancreas. Education is the cornerstone of effective diabetes care. In this implementation project, we aimed to improve compliance with best practices regarding type 1 diabetes educational interventions for adult hospitalized patients. METHODS: This project was guided by the JBI Evidence Implementation Framework. A baseline audit was conducted involving 20 nurses and 20 type 1 diabetes patients who received regular educational measures. Areas of non-compliance were identified and an improvement strategy was implemented. A follow-up audit was then conducted to evaluate the effectiveness of the improvement strategy. The project was conducted in Poland in 2021 in a tertiary referral unit that specializes in the diagnosis and treatment of diabetes. RESULTS: Substantial improvements were noted for all audit criteria after the implementation of strategies to address areas of non-compliance. Use of the education program improved from 0% to 100%. Compliance regarding patients receiving handouts and personalization of the program increased to 100%. We observed a significant improvement from 0% to 80% in the structuring of the program content. CONCLUSIONS: This project successfully improved the quality of education provided for type 1 diabetes patients in all relevant areas. We devised an education program, covering important aspects of diabetes education, with the patients reporting increased satisfaction with the personalized educational measures during their hospital stay. SPANISH ABSTRACT: http://links.lww.com/IJEBH/A215.

Frequency of use and adequacy of Cochrane risk of bias tool 2 in non-Cochrane systematic reviews published in 2020: Meta-research study.

Risk of bias (RoB) assessment is essential to the systematic review methodology. The new version of the Cochrane RoB tool for randomized trials (RoB 2) was published in 2019 to address limitations identified since the first version of the tool was published in 2008 and to increase the reliability of assessments. This study analyzed the frequency of usage of the RoB 2 and the adequacy of reporting the RoB 2 assessments in non-Cochrane reviews published in 2020. This meta-research study included non-Cochrane systematic reviews of interventions published in 2020. For the reviews that used the RoB 2 tool, we analyzed the reporting of the RoB 2 assessment. Among 3880 included reviews, the Cochrane RoB 1 tool was the most frequently used (N = 2228; 57.4%), followed by the Cochrane RoB 2 tool (N = 267; 6.9%). From 267 reviews that reported using the RoB 2 tool, 213 (79.8%) actually used it. In 26 (12.2%) reviews, erroneous statements were used to indicate the RoB 2 assessment. Only 20 (9.4%) reviews presented a complete RoB 2 assessment with a detailed table of answers to all signaling questions. The judgment of risk of bias by the RoB 2 tool was not justified by a comment in 158 (74.2%) reviews. Only in 33 (14.5%) of reviews the judgment in all domains was justified in the accompanying comment. In most reviews (81.7%), the RoB was inadequately assessed at the study level. In conclusion, the majority of non-Cochrane reviews published in 2020 still used the Cochrane RoB 1 tool. Many reviews used the RoB 2 tool inadequately. Further studies about the uptake and the use of the RoB 2 tool are needed.

Methods proposed for monitoring the implementation of evidence-based research: a cross-sectional study.

OBJECTIVES: Evidence-based research (EBR) is the systematic and transparent use of prior research to inform a new study so that it answers questions that matter in a valid, efficient, and accessible manner. This study surveyed experts about existing (e.g., citation analysis) and new methods for monitoring EBR and collected ideas about implementing these methods. STUDY DESIGN AND SETTING: We conducted a cross-sectional study via an online survey between November 2022 and March 2023. Participants were experts from the fields of evidence synthesis and research methodology in health research. Open-ended questions were coded by recurring themes; descriptive statistics were used for quantitative questions. RESULTS: Twenty-eight expert participants suggested that citation analysis should be supplemented with content evaluation (not just what is cited but also in which context), content expert involvement, and assessment of the quality of cited systematic reviews. They also suggested that citation analysis could be facilitated with automation tools. They emphasized that EBR monitoring should be conducted by ethics committees and funding bodies before the research starts. Challenges identified for EBR implementation monitoring were resource constraints and clarity on responsibility for EBR monitoring. CONCLUSION: Ideas proposed in this study for monitoring the implementation of EBR can be used to refine methods and define responsibility but should be further explored in terms of feasibility and acceptability. Different methods may be needed to determine if the use of EBR is improving over time.

Tensile Bond Strength between Different Denture Base Materials and Soft Denture Liners.

(1) Background: Various materials are available for CAD-CAM denture base fabrication, for both additive and subtractive manufacturing. However, little has been reported on bond strength to soft denture liners. Therefore, the aim of this study was to investigate tensile bond strength, comparing between different denture base materials and soft denture liners. (2) Methods: Seven different materials were used for denture base fabrication: one heat-polymerized polymethyl methacrylate, three materials for subtractive manufacturing, two materials for additive manufacturing and one polyamide. Two materials were used for soft denture lining: one silicone-based and one acrylate-based. The study was conducted according to the specification ISO No. 10139-2:2016, and the type of failure was determined. The Kruskal-Wallis test with Dunn's post hoc test was used to analyse the values of tensile bond strength, and Fisher's exact test was used to analyse the type of failure. p Values < 0.05 were considered statistically significant. (3) Results: The tensile bond strength values were not statistically significantly different combining all the materials used for denture base fabrication with the acrylate-based soft denture liner (p > 0.05), and the average values ranged between 0.19 and 0.25 Mpa. The tensile bond strength values of the different denture base materials and silicone-based denture liner were statistically significantly different (p < 0.05), and the average values ranged between 1.49 and 3.07 Mpa. The type of failure was predominantly adhesive between polyamide and both additive-manufactured denture base materials in combination with the acrylate-based soft liner (p < 0.05). (4) Conclusions: The use of digital technologies in denture base fabrication can have an influence on different tensile bond strength values for soft denture liners, with different types of failure when compared with heat-cured PMMA. Similar tensile bond strength values were found between the acrylate-based soft denture liner and denture base materials. Significant differences in tensile bond strength values were found between the silicone-based soft denture liner and denture base materials, where the additive-manufactured and polyamide denture base materials showed lower values than heat-cured PMMA and subtractive-manufactured denture base materials.