Derek Richards

Prophylaxis against infective endocarditis

Methods The guideline was developed by a guideline development group consisting of 12 members and a National Institute for Health and Clinical Excellence (NICE) Short Clinical Guidelines Technical Team using methods described in the NICE guidelines manual (available from www. nice.org.uk/guidelinesmanual). Review and updating Review and updating will take place in line with procedures outlined in the NICE guidelines manual. Recommendations Recommendations were as follows: 1. Healthcare professionals should regard people with the following cardiac conditions as being at risk of developing infective endocarditis (IE): • acquired valvular heart disease with stenosis or regurgitation • valve replacement • structural congenital heart disease, including surgically corrected or palliated structural conditions, but excluding isolated atrial septal defect, fully repaired ventricular septal defect or fully repaired patent ductus arteriosus, and closure devices that are judged to be endothelialised • previous IE • hypertrophic cardiomyopathy 2. Healthcare professionals should offer people at risk of IE clear and consistent information about prevention, including: • the benefits and risks of antibiotic prophylaxis, and an explanation of why antibiotic prophylaxis is no longer routinely recommended • the importance of maintaining good oral health • symptoms that may indicate IE and when to seek expert advice • the risks of undergoing invasive procedures, including nonmedical procedures such as body piercing or tattooing 3. Antibiotic prophylaxis against IE is not recommended: • for people undergoing dental procedures • for people undergoing nondental procedures at the following sites: upper and lower gastrointestinal tract; genitourinary tract (includes urological, gynaecological and obstetric procedures, and childbirth); and upper and lower respiratory tract (includes ear, nose and throat procedures and bronchoscopy) 4. Chlorhexidine mouthwash should not be offered as prophylaxis against IE to people at risk of IE when they undergo dental procedures. 5. Any episodes of infection in people at risk of IE should be investigated and treated promptly to reduce the risk of endocarditis developing. 6. If a person at risk of IE is receiving antimicrobial therapy because they are undergoing a gastrointestinal or genitourinary procedure at a site where there is a suspected infection, the person should receive an antibiotic whose spectrum covers organisms that cause IE. Research recommendations IE is a rare condition and UK research in this area would be facilitated by the availability of a national register of IE cases that could offer data into the ‘case’ arm of proposed case– control studies. Two specific areas of required research were highlighted. First, the risk of developing IE in people who have acquired valvular disease and structural congenital heart disease should be investigated using a population-based cohort study design to allow direct comparison between groups and estimation of both relative and absolute risk. Second, the frequency and level of bacteraemia caused by nonoral daily activities (for example, urination or defecation) requires research to determine quantitatively the frequency and level of bacteraemia.

Oral diseases affect some 3.9 billion people.

Data sourcesMedline, Embase, Lilacs.Study selectionPublished and unpublished observational population-based studies presenting information on the prevalence, incidence, case fatality and cause-specific mortality related to untreated caries, severe periodontitis and severe tooth loss between January 1980 and December 2010. There were no language restrictions. Study quality was assessed using the STROBE checklist (http://www.strobe-statement.org/).Data extraction and synthesisPrevalence estimates were calculated on the database for all age-gender-country-year groups using a specifically developed Bayesian meta-regression tool. Disability-adjusted life-years (DALYs) and years lived with disability (YLDs) metrics were used to quantify the disease burden. Disability weights were calculated based on population-based surveys in five countries (USA, Peru, Tanzania, Bangladesh and Indonesia) and an open Internet survey. Uncertainties in estimates were examined using Monte Carlo simulation techniques with uncertainty levels presented as the 2.5th and 97.5th centiles, which can be interpreted as a 95% UI.ResultsOral diseases remain highly prevalent in 2010 affecting 3.9 billion people. Untreated caries in permanent teeth was the most prevalent condition evaluated for the entire GBD (Global Burden of Disease) 2010 Study with a global prevalence of 35% for all ages combined. Severe periodontitis and untreated caries in deciduous teeth were the 6th and 10th most prevalent conditions, affecting, respectively, 11% and 9% of the global population. Oral conditions combined accounted for 15 million DALYs globally (1.9% of all YLDs and 0.6% of all DALYs), implying an average health loss of 224 years per 100,000 people. DALYs due to oral conditions increased 20.8% between 1990 and 2010, mainly due to population growth and aging. While DALYs due to severe periodontitis and untreated caries increased, those due to severe tooth loss decreased.ConclusionsThe findings highlight the challenge in responding to the diversity of urgent oral health needs world-wide, particularly in developing communities.

Decayed and missing teeth and oral-health-related factors: Predicting depression in homeless people

OBJECTIVE The objective of the study was to determine the effect of dental health status, dental anxiety and oral-health-related quality of life (OHRQoL) upon homeless peoples experience of depression. METHODS A cross-sectional survey was conducted on a sample of homeless people in seven National Health Service Boards in Scotland. All participants completed a questionnaire to assess their depression, dental anxiety and OHRQoL using reliable and valid measures. Participants had an oral examination to assess their experience of tooth decay (decayed and missing teeth). Latent variable path analysis was conducted to determine the effects of dental health status on depression via dental anxiety and OHRQoL using intensive resampling methods. RESULTS A total of 853 homeless people participated, of which 70% yielded complete data sets. Three latent variables, decayed and missing teeth, dental anxiety (Modified Dental Anxiety Scale: five items) and depression (Center for Epidemiological Studies Depression Scale: two factors), and a single variable for OHRQoL (Oral Health Impact Profile total scale) were used in a hybrid structural equation model. The variable decayed and missing teeth was associated with depression through indirect pathways (total standardised indirect effects=0.44, P<.001), via OHRQoL and dental anxiety (χ²=75.90, df=40, comparative fit index=0.985, Tucker-Lewis index=0.977, root mean square error of approximation=0.051 [90% confidence interval: 0.037-0.065]). CONCLUSION Depression in Scottish homeless people is related to dental health status and oral-health-related factors. Decayed and missing teeth may influence depression primarily through the psychological constructs of OHRQoL and, to a lesser extent, dental anxiety.

NHS clinical knowledge summaries.

The UK National Health Service (NHS) Clinical Knowledge Summaries, formerly known as PRODIGY, are part of the National Library for Health and provide a source of evidence-based information and practical know-how relating to the common conditions managed in primary care.

Not all evidence is created equal |[mdash]| so what is good evidence?

We are living in the information age, bombarded from every side by bits and bytes of information. How do we know how good any of it is? One of the aims of Evidence-Based Dentistry is to help the practitioner identify the best evidence. Therefore, we identify here the differing levels of evidence and explain how we will be using these in the journal in future.

GRADING--levels of evidence.

As this journal changes, it is worth highlighting one the key elements of the Summaries we publish in Evidence-based Dentistry, namely the assignment of levels of evidence.

Outcomes, what outcomes?

One of the first stages of the evidencebased approach is to formulate a clinical question. The standard way to do this is by using the well-established PICO (problem, intervention, comparison, outcome) format, as described by Richardson et al. This approach is also taken to define the problem in systematic reviews because poorly focused questions lead to unclear decisions about what research to include and how to summarise it. Regular readers will be aware that many of the systematic review summaries that we publish in Evidence-based Dentistry find that the available evidence is not strong enough to answer the questions posed by the reviewers. One of the strengths of a well-conducted systematic review, the identification of all the available literature on a topic, can be one of its frustrations because the quality of the studies is not strong enough to answer the question posed without bias. Consequently, it tells us not only how little we do know but how much we do not know. As well as the frequent problems with the quality of study-design or of reporting, which both cause difficulty when conducting a systematic review, there is a further difficulty. This is related to the outcome or outcome measures used (a good classification of the types of outcomes available is given by Bader and Ismail). For example, there are a large number of indices for expressing tooth decay and periodontal disease, or potential outcomes in temporomandibular disorders. This causes problems when conducting meta-analyses. Sutherland and Matthews have discussed the issues caused by this, highlighting some of the lessons learned while preparing systematic reviews for clinical guidelines. Hujoel has also argued that the ‘‘lack of a rigorous scientific basis for the measurement of periodontitis has led to changing opinions as to what measures should be used to assess periodontal treatment efficacy and how to interpret changes’’. Hujoel highlights too the difference between true end points, which are tangible to the patients and directly measure how a patient feels, functions or survives (eg, tooth loss or pain or oral health-related quality-of-life measurements), and surrogate end points: the latter are intangible to the patient, such as changes in probing attachment level or gingival crevicular fluid level. In dentistry our focus tends to be on surrogate end points or outcomes although there is an increasing focus on oral health-related quality of life measures. Hujoel does support the use of surrogate end points when two conditions are met, however: K Informativeness: is there evidence that the surrogate predicts the true end point? K Specificity: is the treatment effect on the true endpoint mediated through the surrogate end point? Although the focus of Hujoel’s paper is periodontal disease, many of his arguments are just as relevant to other fields of dental research. In the field of dental caries, work has started on the development of ‘‘ICDAS’’: an international system for caries detection and assessment. The aim of ICDAS is to facilitate caries epidemiology, research and appropriate clinical management. This has the potential to help greatly when combining studies on dental caries into a meta-analysis in the future. There is the scope for similar developments in other fields within dentistry. There is the opportunity for organisations such as the International Association for Dental Research and the World Dental Federation, along with specialist associations, to lead the way to a greater consistency in the outcomes we measure in dentistry. Without this uniformity we are not making the most of the original research that is being carried out and we may not realise the full potential of results combined into systematic reviews.

Review finds that severe periodontitis affects 11% of the world population.

Data sourcesMedline, Embase and LILACS. Chief Dental Officers worldwide were contacted to request conference reports, theses, government reports and unpublished survey data.Study selectionSelection was carried out independently by two reviewers. Longitudinal or crossover studies based on random samples representing national, subnational or community populations with SP defined as; a community periodontal index of treatment needs (CPITN) score of four, a clinical attachment loss (AL) more than 6 mm, or a gingival PD more than 5 mm.Data extraction and synthesisData extraction and synthesis followed Global Burden of Disease (GBD) 2010 standards and modeled using a Bayesian meta-regression tool developed for the GBD 2010. Countries were grouped in 21 regions and seven super-regions by geographical proximity and mean age of death.ResultsSeventy two studies involving 291,170 patients were included. The majority of these (65) were prevalence studies. In 2010, SP was the sixth-most prevalent condition, affecting 10.8% (95% uncertainty interval [UI]: 10.1%-11.6%) or 743 million people worldwide. Between 1990 and 2010 the global age-standardised prevalence of SP in the entire population was static at 11.2% (95% UI: 10.4%-11.9% in 1990 and 10.5%-12.0% in 2010) a non-significant increase from the 1990 incidence of SP. The age-standardised incidence of SP in 2010 was 701 cases per 100,000 person-years (95% uncertainty interval: 599-823), a non-significant increase from the 1990 incidence of SP. Prevalence increased gradually with age, showing a steep increase between the third and fourth decades of life that was driven by a peak in incidence at around 38 years of age.ConclusionsPolicy makers need to be aware of a predictable increasing burden of SP due to the growing world population associated with an increasing life expectancy and a massive decrease in the prevalence of tooth loss throughout the world from 1990 to 2010. These changes underscore the enormous public health challenge posed by SP and are a microcosm of the epidemiologic transition to non-communicable diseases occurring in many countries.

Handsearching still a valuable element of the systematic review

Data sourcesThe Cochrane Methodology Register, Medline, Embase, AMED, Biosis, Cinahl, LISA, and Psycinfo were consulted along with researchers who may have carried out relevant studies.Study selectionStudies were considered eligible if they compared searching by hand with searching one or more electronic databases to identify reports of randomised trials.Data extraction and synthesisthe main outcome measure was the number of reports of randomised trials identified from searches made by hand compared with electronic searching. Data were extracted regarding the electronic database searched, the complexity of electronic search strategy used, the characteristics of the journal reports identified, and the type of trial report identified.ResultsThirty-four studies were included. Handsearching identified between 92 and 100% of the total number of reports of randomised trials found in the various comparisons in this review. Searching Medline retrieved 55%, Embase 49% and Pyscinfo 67%. The retrieval rate of the electronic database varied depending on the complexity of the search. The Cochrane highly sensitive search strategy (HSSS) identified 80% of the total number of reports of randomised trials found; searches categorised as ‘complex’ (including the Cochrane HSSS) found 65% and ‘simple‘ searches found 42%. The retrieval rate for an electronic search was higher when the search was restricted to English-language journals, at 62% versus 39% for journals published in languages other than English. When the search was restricted to full reports of randomised trials, the retrieval rate for an electronic search improved: a complex search strategy retrieved 82% of the total number of such reports of randomised trials.ConclusionsHand searching is still valuable in identifying randomised trials for inclusion in systematic reviews of healthcare, particularly trials reported as abstracts or letters, those published in languages other than English, along with all reports published in journals not indexed in electronic databases. Where time and resources are limited, however, searching an electronic database using a complex search (or the Cochrane HSSS) will identify the majority of trials published as full reports in English language journals, provided, of course, that the relevant journals have been indexed in the database.

Management of unerupted and impacted third molar teeth. A National Clinical Guideline

Aim To assist individual clinicians, hospital departments, hospitals and commissioners of health care to produce local guidelines for the identification of patients who might benefit most from removal of unerupted third molar teeth and those for whom removal is not necessary.Development The guideline was developed in accordance with a process developed by the Scottish Intercollegiate Guidelines Network (SIGN). SIGN is an initiative established in 1993 by the Conference of Royal Colleges and their Faculties in Scotland to sponsor and support the development of national guidelines on a multi-professional basis. Following a systematic review of the literature a development group produced a guideline with recommendations based on the evidence levels set out by the US Agency for Health Care Policy and Research (Table 1). All SIGN guidelines are produced with a summary document, together with more details of the evidence supporting the recommendations. The detailed section of this guideline runs to some 36 pages.Recommendations The guideline provides recommendations relating to when it is and is not advisable to remove wisdom teeth as well as including some strong and other indications for their removal. It also provides advice for the clinical and radiographic assessment of third molars. There is also a grade B recommendation that there is no need for routine radiographic assessment of the unerupted third molar.Review date This guideline was issued in 2000 and will be reviewed in 2002 or sooner if new evidence becomes available. Any updates to the guideline in the interim period will be noted on the SIGN website (http://www.sign.ac.uk)