cross species implications for evidence based dentistry

Issues involving dental care. Questions, answers, theories, and evidence.
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cross species implications for evidence based dentistry

Postby malernee » Tue Sep 13, 2005 7:04 pm

It is now well accepted that it is the host's response to the plaque bacteria, rather than microbial virulence per se, that directly causes the tissue damage

Undisturbed plaque accumulation results in gingivitis. While some individuals with untreated gingivitis will develop periodontitis, not all animals with untreated gingivitis do so. It cannot be predicted which individuals with gingivitis will develop periodontitis. However, animals in which clinically healthy gingivae are maintained will not develop periodontitis. Consequently, the aim in periodontal disease prevention and treatment is to establish and maintain clinically healthy gingivae to prevent periodontitis.
Periodontal disease is a collective term for a number of plaque-induced inflammatory lesions that affect the periodontium. Gingivitis is inflammation of the gingiva and is the earliest sign of disease. Individuals with untreated gingivitis may develop periodontitis. The inflammatory reactions in periodontitis result in destruction of the periodontal ligament and alveolar bone. The result of untreated periodontitis is ultimately exfoliation of the affected tooth. Thus, gingivitis is inflammation that is not associated with destruction (loss) of supporting tissue. It is reversible. In contrast, periodontitis is inflammation where the tooth has lost a variable degree of its support (attachment). It is irreversible.
It is now well accepted that it is the host's response to the plaque bacteria, rather than microbial virulence per se, that directly causes the tissue damage
Evidence based dentistry is a process of systematic evaluation of the research evidence for directed implications and applications in the day-to-day reality of clinical practice. In order to be successful, the integration of research evidence into the practice of clinical dentistry relies on the ability of dentists to identify appropriately designed and conducted research, whose data are correctly analyzed. The current practice of dentistry must increasingly rest on the judicious utilization of the best available evidence. However, questions arise as to the validity of the published research to individual clinical needs in different sociocultural environments, as to whether or not published research can indeed be trusted, and as to what might be the most readily protocols for the evaluation of published research evidence. These issues are discussed herein in the context of the practical example of the chewing sticks, often used in tropical countries as a preventive measure for oral health and hygiene.
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chew sticks in humans

Postby malernee » Tue Sep 13, 2005 7:12 pm

We present below a concerted effort at the utilization of
these approaches is evaluating the evidence in support
of the utilization of chewing sticks for the prevention of
periodontal disease in tropical countries.
4. Chewing Sticks and Oral Health in Tropical
Countries
The Year 2000 Consensus Report on Oral Hygiene by the
World Health Organization (WHO) presented
arguments in support of the use of chewing sticks to help
in the maintenance of oral hygiene in tropical countries.
Indeed, chewing sticks have been used for decades, if
not centuries, in tropical countries of Asia, Africa and the
Americas for dental cleaning purpose and for
preventive oral health17. Little systematic analysis of the
evidence has been done, however. The significance of
this particular body of literature stands in the strong
association between diabetes and the progression of
periodontal disease18. Poor general and oral hygiene and
preventive medicine in tropical countries may favor the
onset and progression of either diabetes and or oral and
periodontal disease.
It is possible and even probable that in many
economically deprived countries whose people are not
afforded the luxury of expensive medications and
medical advances, many diabetics suffer from an
uncontrolled state of their disease. These patients may
be more likely to suffer from oral and periodontal
disease that will likewise remain untreated. In these
areas of world, it would be advantageous to consider
low-cost preventive options to help diminish the
incidence and severity of oral and periodontal disease,
such as chewing sticks that are derived from
endogenous plants.
In many tropical countries in Asia, in Africa and in the
Americas, the use of certain plants as chewing sticks has
been a common practice for teeth cleaning for centuries.
Sticks are usually chewed at one end into a tuft, which is
then used in a brush-like manner to clean the teeth, while
others are simply chewed on. Among the most
commonly used chewing sticks is the Miswak, which is
harvested from the plant Salvadora persica. The value of
the Miswak and of the many other plant species currently
used as chewing sticks throughout the world was
originally believed to rest solely on their mechanical
cleansing action. Recent research suggests several
additional properties of chewing sticks, including
hemostatic, analgesic, antimicrobial, buffering, and antiplaque
forming activity.
We have engaged in a process of systematic examination
of the available research literature on the topic of chewing
sticks essentially by the approach outlined above. We
have examined this literature by means of the protocols
outlined above, or slight modifications thereof. The
research papers that were found to adhere to the stringent
guidelines imperative in research design are discussed
briefly below. Taken together, the research evidence on
chewing sticks supports a relationship between their use
and cleaning effectiveness, pocket depth, gingival
recession, plaque inhibition, and antibacterial activity.
One report describes the oral hygiene habits of Tanzanian
schoolchildren participating in an oral health educational
program, and who were studied by focusing on the
cleaning effectiveness of chewing sticks among habitual
users versus toothbrush users. The report provides
adequate details about the research design such that the
study is straightforwardly reproducible: 124 students
ranging in age from 10 to 13 years were selected to
participate in the study. Subjects were separated into four
groups: 2 experimental groups, one each for chewing
stick and toothbrush use, and 2 control groups also
consisting chewing stick users and toothbrush users.
Each experimental group received oral hygiene
education, while the control group did not. Each habitual
chewing stick user was randomly matched with a
toothbrush user of similar sex, age, and school. The study
conducted single blind oral examinations by one
examiner. Baseline measurements indicated chewing
stick users experienced statistically significant more
plaque, while their gingival condition was not statistically
significantly different from that of their matched
toothbrush counterparts. Three months into the study,
data analysis indicated that subjects in the experimental
groups exhibited a statistically significant reduction in
plaque, and a large, but not significantly significant
decrease in gingival bleeding in contrast to the control
Cross-cultural implications of evidence based dentistry
51
Braz J Oral Sci 1(1): 47-53
group. The degree of reduction in plaque scores between
chewing stick and toothbrush experimental groups was
comparable. Chewing stick users, however, continued
to have higher plaque scores in comparison to
toothbrush users three months into the research. Taken
together, the data suggest that, with proper education,
oral hygiene can be improved regardless of the cleaning
instrument (i.e., toothbrush vs. chewing stick) used.
Data do not suggest that chewing sticks are superior to,
or equal to toothbrushes since chewing sticks users
consistently showed higher levels of plaque. However,
chewing sticks, with proper oral health instruction, may
provide an inexpensive and reasonably effective
alternative in removing plaque and improving gingival
health, when the conventional toothbrushes are not
available19.
These observations were confirmed and expanded in a
related cross-sectional study that used 236 Saudi
Arabian subjects categorized into three groups: a
chewing stick group, a toothbrush group, and a group
who reportedly used both chewing sticks and
toothbrushes in combination. All participants were
examined by two examiners: one interviewed the
patients about their oral hygiene habits, the other
performed all clinical measurements. This approach
sought to reduce examiner bias. Upon clinical
examination, investigators assessed plaque levels,
gingival inflammation, pocket depths, attachment loss,
and gingival recession. Clinical procedures for the
examinations were clearly and thoroughly presented
such that intra-oral examinations and their appropriate
assessment would be adequately reproducible. From
the viewpoint of SESTA, data analysis was somewhat
disputable, since, for instance, measurements such as
the frequency distribution of plaque and the presence of
absence of bleeding on probing ought to have been
analyzed as categorical data, and not by the parametric
test of ANOVA. Nonetheless, valuable information on
pocket depth can still be extrapolated from this study,
and the data indicate that chewing stick users exhibit
greater pocket depths on mid-facial surfaces in
comparison to toothbrush users. Subjects who used
both chewing sticks in conjunction with toothbrushes
were reported to have deeper pocket depths than either
group. It is possible and even probable, as the
investigators suggest, that patients in this group used
the chewing sticks more frequently than the toothbrush,
and that improper or aggressive use of the chewing stick
may be responsible for this type of periodontal damage20.
In an attempt to understand the mechanisms by which
plant extracts may be beneficial to oral health, extracts
were studied for their ability to inhibit the growth or
physical properties of the bacteria suspected of
involvement in the initiation and progression of
destructive periodontal diseases. The extracts, from
plants commonly used in Kenya as chewing sticks, were
tested against three strains each of the proteolytic Gramnegative
organisms, Bacteriodes gingivalis and Bacteroides
intermedius and two strains of the anaerobic spirochaete
Treponema denticola. The source of plants used as chewing
sticks were obtained from a questionnaire distributed to
all primary schools in Kenya in which children were
asked to state what they used to clean their teeth and if
they used a chewing stick. At the end of a six-monthperiod,
over 11,400 responses were received, of which
over 70% claimed to use mswaki (i.e., Miswak). The
plants to be used for further study were identified by a
botanist from a pool of 284 different species and
narrowed down to the five most commonly reported
species. The effects of the plant extracts on bacterial
protease activity, measured by means of sound
biochemical protocols at five different concentrations,
generated data, which were appropriately analyszed
along SESTA criteria. Taken together, the findings suggest
that extracts from plants used in chewing sticks have the
property of interfering with the pattern of growth of
certain bacteria resident in the periodontal plaque flora,
as well as their proteolytic activity. The bacteria
identified to be most sensitive to these extracts were B.
intermedius, B. gingivalis and T. denticola. The findings
also indicated that, one of the plant species tested, C.
hisitanica, is a tropical species introduced in Kenya as a
plantation tree for timber and is widespread in regions
with a high economic potential, suggesting, this plant
species may present the possibility of widespread use as
chewing sticks into countries where these sticks are not
yet readily available21.
In conclusion, the evidence suggests that chewing sticks
are not superior to toothbrushes, although their use may
be beneficial, if moderate, when conventional tools for
oral health are not available. Evidence also supports the
effectiveness of chewing sticks as oral hygiene tools.
Therefore and based on their availability, low-cost, and
cultural acceptability, the research evidence supports the
use of chewing sticks as viable tools for preventive oral
hygiene.
Cross-cultural implications of evidence based dentistry
52
Braz J Oral Sci 1(1): 47-53
Cross-cultural implications of evidence based dentistry
21. Homer KA, Manji F, Beighton D. Inhibition of protease
activitiesofperiodontopathic bacteria by extracts of plants
used in Kenya as chewing sticks (Mswaki). Arch Oral Biol
1990; 35:421-424.
References
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approach to clinical problem-solving. BMJ 1995;
310:1122-1126.
2. Needleman I. Is this good research? Look for CONSORT
andQUORUM. Evid Base Dent 2000; 2:61-62.
3. Chiappelli F, Prolo P. The meta-construct of evidence
based dentistry: part I. Evid Base Dent Pract 2001; 1:159-
165.
4. Chiappelli F, Prolo P. Evidence based dentistry for the 21st
Century. Gen Dent 2002. [in press].
5. Sterne JAC, Smith GD. Sifting the evidence what's wrong
with significance tests? BMJ 2001; 322:226-231.
6. Roemer MI. National Health Systems of the World Vol.2.
New York: Oxford University Press, 1993.
7. Jha P, Mills A, Hanson K, Kumaranayake L, Conteh
L,Kurowski C, Nguyen SN, Olivierea Cruz V, Ranson K,
Vaz LME, Yu S, Morton O, Sachs JD. Improving the health
of the global poor. Science 2002; 295:2036-2041.
8. Sjoegren P, Halling A. How good is the reporting of
randomised clinical trials? Brit Dent J 2001; 192:100-103
9. Moles DR, dos Santos Silva I. Causes, associations and
evaluating evidence; can we trust what we read? Evid
Base Dent 2000; 2:75-78.
10. Garner P, Dickson R, Dans T, Salinas R. Implementing
research findings in developing countries. BMJ 1998;
317:531-535.
11. Hobdell MH, Sheiham A. Barriers to the Promotion of
Dental Health in Developing Countries. Soc Sci Med [A]
1981; 15:817-823.
12. Heloe LA, Haugejorgen A. The rise and fall' of dental
caries: some global aspects of dental caries epidemiology.
Community Dent Oral Epidemiol 1981; 9:294-299.
13. Forrest JL, Miller SA. Enhancing your practice through
evidence-based decision making: Finding the best clinical
evidence. J Evid Base dent Pract 2001; 1:227-236.
14. Begg C, Cho M, Eastwood S, Horton R, Moher D, Olkin I,
Cook,RennieD, Stroup DF. Improving the quality of
reporting of randomized controlled trials. JAMA 1996;
276:637-639.
15. Jadad A. Randomised clinical trials A user's guide.
London: BMJ Books, 1998.
16. Moher D, Cook JC, Eastwood S, Olkin I, Rennie D, Stroup
DF. Improving the quality of reports of meta-analyses of
randomised controlled trials: The QUORUM statement.
Lancet 1999; 354:1896-1990.
17. Wu CD, Darout IA, Skaug N. Chewing sticks: Timeless
natural toothbrushes for oral cleaning. J Periodontal Res
2001; 36:275-284.
18. Moore PA, Orchard T, Guggenheimer J, Weyant RJ.
Diabetesandoralhealth promotion: A survey of disease
prevention behaviors. J Am Dent Assoc 2000; 131:1333-
1341.
19. Van Pattenstein Helderman WH, Munck L, Mushendwa S,
MremaFG. Cleaning effectiveness of chewing sticks
among Tanzania school children. J Clin Periodontol 1992;
19:460-463.
20. Eid MA, Al-Shammery AR, Selim HA, The relationship
between chewing sticks (Miswak) and periodontal health
II: Relationship to plaque, gingivitis, pocket depth and
attachment loss. Quintessence Int 1990; 21:1019-1022.
53
Braz J Oral Sci 1(1): 47-53
malernee
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fluoride tablets to prevent dental disease

Postby malernee » Tue Sep 13, 2005 7:21 pm

J Public Health Dent. 1992 Winter;52(2):111-6. Related Articles, Links


A comparison of the caries-preventive effects of fluoride mouthrinsing, fluoride tablets, and both procedures combined: final results after eight years.

Driscoll WS, Nowjack-Raymer R, Selwitz RH, Li SH, Heifetz SB.

Disease Prevention Section, National Institute of Dental Research, National Institute of Health, Bethesda, MD 20816.

This paper presents final results of an eight-year clinical trial designed to compare the caries-preventive benefits of two self-administered fluoride procedures when used separately and in combination with one another. Children in kindergarten and first grade residing in Springfield, Ohio, a nonfluoridated community, were assigned randomly within school to one of three groups that either (a) rinsed once a week in school with a 0.2 percent neutral NaF solution; (b) chewed, rinsed with, and then swallowed daily in school a neutral 2.2 mg NaF tablet; or (c) carried out both procedures. At baseline (1981), 1,640 participants were examined clinically using the DMF surface index. Findings for 640 children remaining after eight years show that subjects in the combination group experienced a mean caries increment of 2.40 DMFS, 15.2 percent lower than the mean score of 2.83 DMFS for children in the tablet group and 32.8 percent lower than the 3.57 DMFS for those in the rinse group. Only the difference in incremental caries scores between the combined fluoride procedure and the fluoride rinse was statistically significant (P less than .05). The pattern of these findings is similar to that found on the two interim examinations. Even though the combined regimen showed an additional caries-preventive benefit compared with the rinse, considerations of cost effectiveness and feasibility do not support changing an ongoing rinse program to one that employs both procedures. For new programs the best choice appears to be the tablet procedure alone.
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OSCILLATION TOOTHBRUSHES BEST study

Postby malernee » Tue Sep 13, 2005 7:23 pm

ROTATIONAL OSCILLATION TOOTHBRUSHES BEST AT REDUCING PLAQUE, GINGIVITIS, ACCORDING TO MAJOR, INDEPENDENT REVIEW

Boston, January 11, 2003---Powered toothbrushes with rotational oscillation action are more effective in removing plaque and reducing gingivitis than are manual toothbrushes or other types of powered brushes, an independent, international research team reported today.

The finding was announced by The Cochrane Collaboration, an independent, international, nonprofit organization, at a conference sponsored by the Forsyth Center for Evidence-Based Dentistry (EBD) www.forsyth.org/ebd in Boston.

"Rotational oscillation toothbrushes removed up to 11 per cent more plaque and reduced gingival bleeding by up to 17 percent more than did manual or other power toothbrushes," said William Shaw, PhD, MScD, joint co-coordinating editor of the Cochrane Oral Health Group, which analyzed data from clinical trials conducted over 37 years. The Cochrane Oral Health Group is one of 50 review groups of The Cochrane Collaboration, which provides and disseminates systematic reviews of health research findings.

Richard Niederman, DMD, Director of the Forsyth Center for Evidence-Based Dentistry called the study: "one of the most comprehensive independent reviews of powered toothbrushes ever conducted." The EBD Center, originally established at the Harvard School of Dental Medicine, moved to The Forsyth Institute in 2001. Forsyth is an independent, nonprofit research institute focused on oral, craniofacial and related biomedical science.

In the Cochrane study, six reviewers independently extracted data from reports on twenty-nine clinical trials involving a total of 2547 participants in North America, Europe and Israel. The clinical trials, conducted between 1964 and 2001, compared the effectiveness of all forms of manual and six types of power toothbrushes with mechanically moving heads when used short-term (one month) and long-term (up to three months).

The reviewers analyzed studies of five types of powered toothbrushes in addition to those with rotational oscillation action. The five others included brushes with side-to-side action, counter-oscillational action, circular action, sonic and ultrasonic action, and unknown action. The short-term comparison between sonic and manual brushes reached borderline statistical significance for plaque removal, but data on long-term results were limited because only one trial was available for analysis.

Only the rotational oscillation toothbrushes proved more effective than manual toothbrushes in reducing plaque and gingivitis.

Shaw emphasized that the review results do not indicate that toothbrushing is only worthwhile with a powered toothbrush. "There is overwhelming evidence that toothbrushing reduces gingivitis," he said. "Brushing may prevent periodontitis, and brushing certainly prevents tooth decay if used with fluoride toothpaste. These benefits occur whether the brush is manual or powered."

Among powered toothbrushes included in the study were: Braun Oral B Plaque Remover (rotational oscillation); Philips Sonicare (sonic side-to-side action); Interplak (counter oscillation); Teledyne Aqua Tech (circular action); Ultrasonex brush (ultrasonic side-to-side action); and Rowenta Dentiphant, Rowenta, and Plaque Dentacontrol Plus (unknown actions).

Toothbrushes subjected to trials briefer than one month and those brought to market after 2001 were not included in the review.

Because the trials examined were of limited duration and did not test brushes for durability, the research did not lead to recommendations for any particular toothbrush type or brand.

Powered brushes were first introduced commercially in the early 1960s and have become an established alternative to manual methods of toothbrushing. In the United States, the volume of power toothbrush sales tripled from approximately three percent of all toothbrush sales in 1999 to more than nine percent in 2001, according to the Journal of Contemporary Dental Practice. In the United Kingdom, the volume of sales of powered toothbrushes nearly doubled each year between 1999 and 2001, increasing from two percent of total sales of all toothbrushes in 1999 to seven percent in 2001, the report states.

The review was published in the January edition of The Cochrane Library, a regularly updated collection of high quality information on health care.

*

The Cochrane Collaboration (www.cochrane.org) is an international nonprofit organization whose goal is to help consumers and clinicians make well-informed decisions about healthcare by preparing, maintaining and promoting accessibility of systematic reviews on the effects of healthcare interventions. The Collaboration comprises some 50 topic-based collaborative review groups and 8000 contributors in more than 70 countries around the world. The Cochrane Collaboration’s US headquarters are located at Brown University, in Providence, Rhode Island with branches in Boston and San Francisco. The Cochrane Collaboration also has Centers in Australia, Brazil, Canada, China, South Africa, Holland, Germany, Italy, Spain, Norway, and the UK.


*

NOTE TO JOURNALISTS: For copies of the review go to http://www.update-software.com/cochrane/abstract.htm
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