Quality analysis of the clinical practice guidelines for management of impacted maxillary central incisors: a systematic review.

PURPOSE: To assess the quality of clinical practice guidelines (CPG) for management of impacted central incisors. METHODS: Search was performed in PubMed, LILACS, Web of Science, EMBASE, Scopus, and Cochrane databases, and guideline-focused databases/repositories on 15-09-2022 without any limitations and was updated on 15-07-2023. Grey literature search was also performed. Two independent reviewers were involved in the study selection and data extraction. Quality assessment of the included CPG was performed by four independent appraisers using the AGREE-II instrument. The degree of agreement among the appraisers was calculated using the intraclass correlation coefficient (ICC). RESULTS: Five CPG were included in the review. The Ministry of Health, Malaysia (MHM) guideline obtained the highest scores in all six domains of AGREE-II and an overall score of 73% demonstrating the "highest" quality. The remaining four guidelines obtained overall "low-quality" scores ranging from 34.57-37.52%. The ICC scores ranged from 0.530 to 0.990 for various domains of AGREE-II. CONCLUSION: MHM guidelines demonstrated high-quality scores in domains of 'scope and purpose', 'clarity of presentation', 'applicability domain', and 'editorial independence', while others were found to have moderate or low quality. This review identified areas that can be addressed by future guideline developers to avoid these discrepancies.

Evaluation of dental trials comparing baseline differences using p values.

INTRODUCTION: Significance testing for comparison of the baseline differences between the intervention arms has received a strong condemnation. The goal of this study was to assess the prevalence of randomized controlled trials (RCTs) comparing the baseline characteristics between intervention groups using significance tests in top ten impact factor dental journals. MATERIALS AND METHODS: RCTs published in 10 high impact factor dental journals were searched in PubMed database. Literature search was limited to time duration of 5 years from September 2012 to August 2017. RESULTS: We analysed 521 RCTs after excluding 47 non-RCT articles from the total of 568 articles. Baseline demographic characteristics table was not reported in 45.9% of the RCTs and 26.2% of the RCTs did not report table of baseline clinical characteristics. In 38.9% of the studies, significance testing was employed to compare baseline differences between the intervention arms. CONCLUSIONS: Many trials published in the reputed dental journals failed to follow the recommendations of CONSORT statement regarding reporting of baseline tables and avoiding comparison of baseline differences with significance test.

An exploratory quality assessment of orthodontic clinical guidelines using the AGREE II instrument.

OBJECTIVES: Clinical guidelines act as a means of assisting clinicians in improving the quality of healthcare provided. We aim to assess the quality of currently available international orthodontic guidelines. MATERIALS AND METHODS: A cross-sectional systematic assessment of orthodontic clinical guidelines was undertaken. A Medline search using the keywords 'guideline', 'orthodontics', and 'dent', and search of specific dental and orthodontic organization websites for orthodontic-related clinical guidelines. Relevant guidelines published between 1999 and 2012 in English were identified. Draft guidelines and endorsements were excluded. The quality of each guideline was evaluated by a single calibrated assessor using the AGREE II instrument. Variation in the quality of guidelines produced by different organizations was also assessed. RESULTS: Seventeen guidelines were included in this study. Overall, the reporting of scope and purpose (84.31, 95% CI: 70.91-97.72) and clarity of presentation (75.49, 95% CI: 61.68-89.3) domains of the AGREE II instrument were deemed of high quality. Lower scores were obtained for the following domains: rigour of development (52.08, 95% CI: 37.59-66.57), editorial independence (47.06, 95% CI: 20.6-73.51), stakeholder agreement (46.41, 95% CI: 29.66-63.15), and applicability (27.45, 95% CI: 8.26-46.64). There was a noted difference in the individual domain scores of orthodontic guidelines produced by the different organizations. CONCLUSIONS: In relation to the AGREE II instrument, the quality of orthodontic guidelines for use in clinical practice are deemed sub-optimal. Variation in the quality of guidelines produced different organizations is evident.

Leading the Dental Quality Movement: A Dental Quality Alliance Perspective.

Changing regulatory priorities set forth by the Affordable Care Act and recent activities of the Centers for Medicare and Medicaid Services clearly prioritize the need to improve the quality of health care in both the public and private sectors. As the largest multistakeholder organization focused on oral health care quality measurement and improvement, the Dental Quality Alliance is leading the way in establishing standardized and valid quality measures applicable in both private and public sectors.

The evidence from systematic reviews and meta-analyses published in orthodontic literature. Where do we stand?

AIM: To analyse meta-analyses included in systematic reviews (SRs) published in leading orthodontic journals and the Cochrane Database of Systematic Reviews (CDSR) focusing on orthodontic literature and to assess the quality of the existing evidence. MATERIALS AND METHODS: Electronic searching was undertaken to identify SRs published in five major orthodontic journals and the CDSR between January 2000 and June 2014. Quality assessment of the overall body of evidence from meta-analyses was conducted using the Grading of Recommendations Assessment, Development and Evaluation working group (GRADE) tool. RESULTS: One hundred and fifty-seven SRs were identified; meta-analysis was present in 43 of these (27.4 per cent). The highest proportion of SRs that included a meta-analysis was found in Orthodontics and Craniofacial Research (6/13; 46.1 per cent), followed by the CDSR (12/33; 36.4 per cent) and the American Journal of Orthodontics and Dentofacial Orthopaedics (15/44; 34.1 per cent). Class II treatment was the most commonly addressed topic within SRs in orthodontics (n = 18/157; 11.5 per cent). The number of trials combined to produce a summary estimate was small for most meta-analyses with a median of 4 (range: 2-52). Only 21 per cent (n = 9) of included meta-analyses were considered to have a high/moderate quality of evidence according to GRADE, while the majority were of low or very low quality (n = 34; 79.0 per cent). CONCLUSIONS: Overall, approximately one quarter of orthodontic SRs included quantitative synthesis, with a median of four trials per meta-analysis. The overall quality of evidence from the selected orthodontic SRs was predominantly low to very low indicating the relative lack of high quality of evidence from SRs to inform clinical practice guidelines.

Randomized controlled trial: the gold standard or an unobtainable fallacy?

BACKGROUND: This article is the result of a debate at the European Journal of Orthodontics Open Session in 2013 in Reykjavik, Iceland. OBJECTIVE: The aim of this article is to highlight some of the strengths and weakness of clinical orthodontic research, with particular emphasis on randomized controlled trials (RCT). The ultimate aim of improving clinical orthodontic research in general. DESIGN: This article is organized into two sections with arguments for and against RCTs. The backgrounds to evidence-based evaluation and the level or quality of evidence in trials are discussed. The article emphasises what makes high quality clinical research, and gives practical advice including examples of tips and potential pitfalls for those undertaking clinical research. RESULTS AND CONCLUSION: The overriding message is constructive and it is hoped that the article serves as an aid in evaluating, designing, conducting, and reporting clinical research.

Lack of high-quality studies comparing the effectiveness, and cost-effectiveness, of dental auxiliaries and dentists in performing dental care.

DATA SOURCES: Cochrane Effective Practice and Organisation of Care (EPOC) Group's Specialised Register; Cochrane Oral Health Group's Specialised Register; the Cochrane Central Register of Controlled Trials Medline; Embase; CINAHL; Cochrane Database of Systematic Reviews; Database of Abstracts of Reviews of Effectiveness; five other databases and two trial registries. A number of dental journals were hand-searched and a grey literature search preformed. STUDY SELECTION: Randomised controlled trials (RCTs), non-randomised controlled trials (NRCTs), controlled before and after studies (CBAs) and interrupted time series (ITSs) were considered. Selection was conducted independently by two reviewers. DATA EXTRACTION AND SYNTHESIS: Three reviewers extracted data and assessed risk of bias. Meta-analysis was not possible so a narrative summary was presented. RESULTS: Four studies evaluated sealant placement; three found no evidence of a difference in retention rates of those placed by dental auxiliaries and dentists over a range of follow-up periods (six to 24 months). One study found that sealants placed by a dental auxiliary had lower retention rates than ones placed by a dentist after 48 months (9.0% with auxiliary versus 29.1% with dentist); but the net reduction in the number of teeth exhibiting caries was lower for teeth treated by the dental auxiliary than the dentist (three with auxiliary versus 60 with dentist, P value < 0.001). One study showed no evidence of a difference in dental decay after treatment with fissure sealants between groups. One study comparing the effectiveness of dental auxiliaries and dentists performing ART reported no difference in survival rates of the restorations (fillings) after 12 months. CONCLUSIONS: We only identified five studies for inclusion in this review, all of which were at high risk of bias, and four were published more than 20 years ago, highlighting the paucity of high-quality evaluations of the relative effectiveness, cost-effectiveness and safety of dental auxiliaries compared with dentists in performing clinical tasks. No firm conclusions could be drawn from the present review about the relative effectiveness of dental auxiliaries and dentists.

The trend of quality of publications in endodontic surgery: a 10-year systematic survey of the literature.

OBJECTIVES: The aims of the present systematic literature analysis were to evaluate, over a 10-year period, the trend of the proportion of RCT, SR, MA published on endodontic surgery, and to investigate if the impact factor (IF) of the main endodontic Journals correlates with the proportion of RCT, SR, MA they publish. METHODS: An electronic search of the RCT, SR and MA published on the topic "endodontic surgery" from 2001 to 2010 was performed on Medline and Cochrane CENTRAL database using specific search terms combined with Boolean operators. Endodontic Journals impact factor was retrieved by the Thomson Scientific database. The proportion of each study type over the total number of articles on endodontic surgery published per year was estimated. The correlation between the number of high-evidence level studies published on the main endodontic Journals and the IF of such Journals per year was estimated. RESULTS: From a total of 900 articles published in 2001-2010 on endodontic surgery, there were 114 studies of high evidence level. A significant increase of the proportion of either RCT, SR and MA over the years was found. A modest to unclear correlation was found between the Journal IF and the number of high-evidence articles published. CONCLUSIONS: There is a positive trend over the years among researchers in performing studies of good quality in endodontic surgery. The impact factor of endodontic Journals is not consistently influenced by publication of high-evidence level articles.

Methodological quality and implications for practice of systematic Cochrane reviews in pediatric oral health: a critical assessment.

BACKGROUND: To ensure evidence-based decision-making in pediatric oral health, Cochrane systematic reviews that address topics pertinent to this field are necessary. We aimed to identify all systematic reviews of paediatric dentistry and oral health by the Cochrane Oral Health Group (COHG), summarize their characteristics and assess their methodological quality. Our second objective was to assess implications for practice in the review conclusions and provide an overview of clinical implications about the usefulness of paediatric oral health interventions in practice. METHODS: We conducted a methodological survey including all paediatric dentistry reviews from the COHG. We extracted data on characteristics of included reviews, then assessed the methodological quality using a validated 11-item quality assessment tool (AMSTAR). Finally, we coded each review to indicate whether its authors concluded that an intervention should be implemented in practice, was not supported or was refuted by the evidence, or should be used only in research (inconclusive evidence). RESULTS: We selected 37 reviews; most concerned the prevention of caries. The methodological quality was high, except for the assessment of reporting bias. In 7 reviews (19%), the research showed that benefits outweighed harms; in 1, the experimental intervention was found ineffective; and in 29 (78%), evidence was insufficient to assess benefits and harms. In the 7 reviews, topical fluoride treatments (with toothpaste, gel or varnish) were found effective for permanent and deciduous teeth in children and adolescents, and sealants for occlusal tooth surfaces of permanent molars. CONCLUSIONS: Cochrane reviews of paediatric dentistry were of high quality. They provided strong evidence that topical fluoride treatments and sealants are effective for children and adolescents and thus should be implemented in practice. However, a substantial number of reviews yielded inconclusive evidence.

BSP Implementation of prevention and treatment of peri-implant diseases - The EFP S3 level clinical practice guideline.

OBJECTIVES: to adapt the supranational European Federation of Periodontology (EFP) Prevention and Treatment of Peri-implant Diseases - The EFP S3 Level Clinical Practice Guideline for UK healthcare environment, taking into account a broad range of views from stakeholders and patients. SOURCES: This UK version, based on the supranational EFP guideline [1] published in the Journal of Clinical Periodontology, was developed using S3-level methodology, combining assessment of formal evidence from 13 systematic reviews with a moderated consensus process of a representative group of stakeholders, and accounts for health equality, environmental factors and clinical effectiveness. It encompasses 55 clinical recommendations for the Prevention and Treatment of Peri-implant Diseases, based on the classification for periodontal and peri­implant diseases and conditions [2]. METHODOLOGY: The UK version was developed from the source guideline using a formal process called the GRADE ADOLOPMENT framework. This framework allows for adoption (unmodified acceptance), adaptation (acceptance with modifications) and the de novo development of clinical recommendations. Using this framework, following the S3-process, the underlying evidence was updated and a representative guideline group of 111 delegates from 26 stakeholder organisations was assembled into four working groups. Following the formal S3-process, all clinical recommendations were formally assessed for their applicability to the UK and adoloped accordingly. RESULTS AND CONCLUSION: Using the ADOLOPMENT protocol, a UK version of the EFP S3-level clinical practice guideline for the Prevention and Treatment of Peri-implant Diseases was developed. This guideline delivers evidence- and consensus-based clinical recommendations of direct relevance to the UK healthcare community including the public. CLINICAL SIGNIFICANCE: The S3-level-guidelines combine evaluation of formal evidence, grading of recommendations and synthesis with clinical expertise of a broad range of stakeholders. The international S3-level-guideline was implemented for direct clinical applicability in the UK healthcare system, facilitating a consistent, interdisciplinary, evidence-based approach with public involvement for the prevention and treatment of peri­implant diseases.

Changes in orthodontic treatment modalities in the past 20 years: exploring the link between technology and scientific evidence.

STATEMENT OF THE ISSUE: Is there a link between the many perceived advances in orthodontic techniques/therapy and science in the past 20 years? The purpose of this paper is to take five topics and match the perceptions with the scientific evidence. The variety of appliances and the swings in treatment philosophy have been dramatic, including the swing from extraction to non-extraction therapy, the introduction of space-age wires, appliances that grow mandibles, the introduction and extraordinary growth of Invisalign, and reduced friction brackets to reduce treatment time, all with claims by manufacturers of better results than ever before. The focus is on faster treatment, reduced visits/appointments and superior results. Most of these 'advancements' represent what has been the 'juggernaut of technology'. Five questions are posed, and an evidence-based approach is used to critically examine the literature in these selected topics.

Diagnosis of the condition of the dental pulp: a systematic review.

The aim of this systematic review was to appraise the diagnostic accuracy of signs/symptoms and tests used to determine the condition of the pulp in teeth affected by deep caries, trauma or other types of injury. Radiographic methods were not included. The electronic literature search included the databases PubMed, EMBASE, The Cochrane Central Register of Controlled Trials and Cochrane Reviews from January 1950 to June 2011. The complete search strategy is given in an Appendix S1 (available online as Supporting Information). In addition, hand searches were made. Two reviewers independently assessed abstracts and full-text articles. An article was read in full text if at least one of the two reviewers considered an abstract to be potentially relevant. Altogether, 155 articles were read in full text. Of these, 18 studies fulfilled pre-specified inclusion criteria. The quality of included articles was assessed using the QUADAS tool. Based on studies of high or moderate quality, the quality of evidence of each diagnostic method/test was rated in four levels according to GRADE. No study reached high quality; two were of moderate quality. The overall evidence was insufficient to assess the value of toothache or abnormal reaction to heat/cold stimulation for determining the pulp condition. The same applies to methods for establishing pulp status, including electric or thermal pulp testing, or methods for measuring pulpal blood circulation. In general, there are major shortcomings in the design, conduct and reporting of studies in this domain of dental research.

Quality of randomised controlled trials in dentistry.

Randomised controlled trials (RCTs) are regarded as the best study designs to test the efficacy of medical and dental intervention. Many reports, however, have shown that at the moment the quality of dental RCT reports is still poor, and further efforts to improve it are necessary. It has been suggested that trials that are not well designed provide biased estimates of the treatment effects and that a journal's impact factor is not related to the quality of RCTs published. For these reasons, before trusting RCT reports, a careful assessment of the study selected is needed. Randomisation, blinding, allocation concealment, drop outs analysis are essential quality components of RCTs. Many systems for RCTs quality assessment are available. In this report the concept of quality of RCTs will be critically evaluated and the most commonly used instruments available for quality assessment of RCTs in dental research will be reviewed.

Evidence-based periodontal plastic surgery: an assessment of quality of systematic reviews in the treatment of recession-type defects.

OBJECTIVE: To assess methods, quality and outcomes of systematic reviews (SRs) conducted to evaluate the effectiveness of root coverage (RC) procedures in the treatment of recession-type defects (RTD). METHODS: MEDLINE and EMBASE were searched up to and including April 2010 to identify SRs investigating the effectiveness/efficacy of surgical interventions for the treatment of patients with RTD. Searching was conducted independently by two reviewers, and data extraction was based on the methodological criteria applied and on the effects of interventions reported by each SR. The checklist proposed by Glenny and colleagues, the Overview Quality Assessment Questionnaire and the "Assessment of Multiple systematic Reviews", instrument were used to assess the quality of SRs. Additionally, the methodological criteria applied by included reviews were compared with those proposed by the Cochrane Collaboration. RESULTS: Search strategy identified 716 potentially eligible articles, of which 12 papers regarding 10 SRs were included in the study. Results from different SRs showed that subepithelial connective tissue grafts associated or not to coronally advanced flaps can be used to reduce recession depth and improve the width of keratinized tissue. All quality assessment tools showed that most of the SRs were of good methodological quality, but they also highlighted key points that could be improved in future reviews. Only two SRs followed in full the guidelines proposed by the Cochrane Collaboration. CONCLUSIONS: All SRs agree that RC may be anticipated by different surgical procedures. However, differences in the methodological quality between reviews were quite evident, and thus making a clear indication that there is a need of standardization of the methods that will be applied by future SRs. As a result, a standardized checklist for reporting SRs was proposed by the authors.

Critical appraisal of methods used in randomized controlled trials of treatments for temporomandibular disorders.

AIMS: To evaluate the quality of methods used in randomized controlled trials (RCTs) of treatments for management of pain and dysfunction associated with temporomandibular muscle and joint disorders (TMJD) and to discuss the implications for future RCTs. METHODS: A systematic review was made of RCTs that were implemented from 1966 through March 2006, to evaluate six types of treatments for TMJD: orthopedic appliances, occlusal therapy, physical medicine modalities, pharmacologic therapy, cognitive-behavioral and psychological therapy, and temporomandibular joint surgery. A quality assessment of 210 published RCTs assessing the internal and external validity of these RCTs was conducted using the Consolidated Standards of Reporting Trials (CONSORT) criteria adapted to the methods of the studies. RESULTS: Independent assessments by raters demonstrated consistency with a mean intraclass correlation coefficient of 0.63 (95% confidence interval). The mean percent of criteria met was 58%, with only 10% of the RCTs meeting the four most important criteria. CONCLUSIONS: Much of the evidence base for TMJD treatments may be susceptible to systematic bias and most past studies should be interpreted with caution. However, a scatter plot of RCT quality versus year of publication shows improvement in RCT quality over time, suggesting that future studies may continue to improve methods that minimize bias.

Systematic reviews of topical fluorides for dental caries: a review of reporting practice.

This paper aims to assess systematic reviews on the caries-preventive effect of topical fluorides, identifying key content and reporting quality issues to be considered by researchers planning a review in this area. Published systematic reviews and meta-analyses of any topical fluoride intervention for caries control were included. Relevant databases were searched (December 2009), along with reference lists of included publications. Thirty-eight reports were identified and assessed. A majority of these focused on the child/adolescent population, fluoride toothpastes, no treatment/placebo comparisons, and had caries increment as the main outcome. Complete reporting of eligibility criteria (PICOS) was uncommon, except in Cochrane reviews. Less than half reported searching multiple sources and only one third reported a search strategy. Duplicate study selection and data extraction was reported in 27 (71%) and 16 (42%) reviews, respectively; quality assessment of included studies was not reported in one third of the reviews. Meta-analysis was reported in 20 (52%) reviews, with six not reporting the methods of synthesis used, 17 formally assessing heterogeneity, and 12 reporting analyses for its exploration. This study shows that some content features have been covered more often than others in existing fluoride reviews, while some relevant features are yet to be addressed. Also, reporting of several methodological aspects are below an acceptable level, except for Cochrane reviews. Current reporting guidelines for systematic reviews of interventions (e.g. PRISMA) and sources of high-quality existing reviews (e.g. The Cochrane Library) should be closely followed to enhance the validity and relevance of future topical fluoride reviews.