Introduction and Objective:

Dental anxiety poses a significant barrier to treatment compliance, the use of dental services and ability to maintain an adequate oral health quality of life. Dental anxiety prevalence is high with approximately 10-20% occurrence in the population of the United States and despite the significant advancements in dental materials and technology, dental anxiety levels have remained relatively stable since the mid-1900s (Sohn & Amid, 2005; Locker, Liddell, & Shapiro, 1999; (Smith & Heaton, 2003). There exists a strong association between dental anxiety, poorer oral health status and oral health quality of life (Kumar et al., 2009; Armfield, Stewart, & Spencer, 2007; Mcgrath & Bedi, 2004; Berggren & Gunnell, 1984). The aim of this study is to conduct comparative effectiveness research to find out which dental anxiety interventions have shown to be more effective in decreasing dental anxiety in adult dental patients.

Methods: The research hypothesis was that cognitive behavioral therapy applied to adult dental patients with dental anxiety is more effective in reducing dental anxiety than other intervention modalities focused on reducing dental anxiety. Search for systematic reviews, randomized clinical trials, and cohort studies were done using PubMed, the Cochrane Library, and Emabase databases. The relevance of the identified systematic review, clinical trials, and cohort studies to the study and PICOTS question was assessed using the inclusion and exclusion criteria. The quality of the evidence and clinical relevance analysis achieved using validated and reliable instruments by two independent readers and all disagreements resolved by discussion after establishing the inter-rater reliability of the two readers. The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) was utilized to assess the quality and clinical relevance of six systematic reviews. The CONsolidated Standards of Reporting Trials (CONSORT 2010) instrument was utilized to evaluate the quality and clinical relevance of clinical trials. The Strengthening the reporting of Observational Studies in Epidemiology (STROBE) instrument was utilized to evaluate the quality and clinical relevance of cohort studies. Acceptable sampling was done using established cutoff scores. Meta-analysis could not be done due to heterogeneity of available data.

Results: Two out of six systematic reviews, four out of fifty-nine randomized control trials, and four out of fifteen cohort studies were considered high-quality studies. So out of eighty studies, ten were included.

Conclusions:

A quantitative and qualitative consensus could not be formed due to heterogeneity of data and study design; however, multiple qualitative consensuses could be formed. For example, atraumatic restorative treatment (ART) can lower anxiety more than conventional treatment, lavender scent is effective in reducing state anxiety but not anticipatory anxiety, auricular acupuncture is more effective than placebo sham acupuncture in reducing dental anxiety, and either type of acupuncture is more effective than no acupuncture. Furthermore, premedication with the anxiolytic valium and systematic desensitization have both shown to be effective in reducing dental anxiety, while brief relaxation and music distraction are both effective in reducing dental anxiety as well, though brief relaxation is more effective in patients with high dental anxiety. We can neither accept nor reject our hypothesis because while cognitive behavioral therapy was shown to be effective in one study, and related cognitive therapy and psychological intervention was shown to be effective in two other studies, these were not demonstrated to be more effective than other anxiety treatments shown to be effective in studies where cognitive behavioral therapy was not compared. Thus, since cognitive behavioral therapy was not compared to other intervention types shown to be effective, we cannot conclude whether cognitive behavioral therapy is or is not more effective in treating dental anxiety. To do so, a high-quality study comparing the intervention modalities shown to be effective in all the high-quality studies in our bibliome is needed.

ABSTRACT OF THE THESIS

Background.

Evidence based Dentistry and Patient Centered Care are the two paradigms which influence the process of clinical decision making in modern dental care. Although they are complementary means to improve quality, they may seem at odds with each other. In the last decade, a need has emerged to examine the intersection of these two paradigms. Meta-analyses are a hallmark of evidence based dentistry as they succeed in showing statistically significant results by combining the results from individual studies. However, they are limited when the individual studies are heterogeneous. Meta-regression may help investigate this heterogeneity, but its limited ability to identify which patient features are related to the size of treatment effect is answered by using an individual patient data approach. Poor reporting of individual patient data meta-analysis diminishes its value to clinicians, policy makers, and other users. Our goal is to develop and validate a tool to assess the quality of an individual patient data meta-analysis.

Methods.

We develop a tool based on the literature available in the field of Individual patient data meta-analysis. A modification of the PRISMA is done without altering its intent of use. In total, twelve Individual patient data meta-analyses in oral and maxillofacial medicine are identified to validate the tool and to establish its reliability. This is carried out by two independent readers who are standardized and trained to avoid misinterpretation of the Tool items. A Pearson's r coefficient is calculated to test inter-rater; intra-rater reliability and criterion validity.

Results

A 9 item tool with a minimum of 3 criteria per item is constructed. The lowest score possible per question is 1 and the highest score possible per question is 4. The minimum total score possible is 9 and the maximum total score possible is 36. The new instrument has high content validity by virtue of its construction process. Testing the tool for criterion validity yields a Pearson's r of 0.957. The tool has construct validity based on the evidence of Test content, Internal structure, Response process, Relations to other variables, and Consequences of testing. It is also reliable with a Pearson's r of 0.927 for inter-rater reliability and a Pearson's r of 0.972 and 0.904 for intra-rater reliability.

Discussion

Our study led to the development of a novel instrument specifically designed for assessing the quality of individual patient data meta-analysis. The tool scores for the 12 papers quantified the degree to which each paper satisfied certain criteria that are established in the literature as determinant factors of highest quality meta-analysis in general, and individual patient data meta-analysis in particular. The tool has significant implications for clinicians and researchers. We recognize the need for further testing of the Tool to increase its validity. New evidence in areas of methodology of IPDMA may call for a need to update the Tool.

Introduction:

Dental caries is one of the most common chronic diseases in the world. In daily dental practice, dentists are treating many cases where the destruction from caries involves enamel and dentin and reaches the pulp. One of the main objectives of a restorative dental procedure is the protection of the pulp to maintain its vitality, and pulp capping has been shown to be very successful in this regard for cases of reversible pulpitis. When the carious lesion is in close proximity to the pulp but the pulp tissue has not been exposed, indirect pulp capping is performed using any of several liner or base materials prior to placing the final restoration. On the other hand, if there is a direct exposure to the pulp, treatment with direct pulp capping requires careful and specific selection of the pulp capping material.

In the past decade, there has been a debate on the best available material to be used in direct pulp capping. Calcium hydroxide was considered the gold standard material used for direct pulp capping for decades prior to the introduction of Mineral Trioxide Aggregate (MTA). Many studies have been conducted to study the effectiveness of these materials when used in direct pulp capping. The purpose of this study is to identify the best available evidence on direct pulp capping material and determine if MTA is more effective than calcium hydroxide.

Methods:

The research strategy included search engines and hand searching to obtain randomized clinical trials and systematic reviews relevant to the research question. The search engines used were PubMed, ADA Evidence Base Database, Cochrane library and Web of science. Two readers were involved in validating the quality of the evidence and strength of recommendation in randomized clinical trials using Ex-GRADE and the revised risk of bias instruments. Acceptable sampling will be completed prior to performing Meta-analysis. Similarly, (R-AMSTAR) instrument was used to quantify the quality of systematic reviews.

Results:

The bibliome consists of seven clinical trials, five observational studies and four systematic reviews. The acceptable sampling analysis produced three systematic reviews, two clinical trials and four observational studies. Qualitative assessment of the accepted studies confirmed that MTA is more effective and shows better clinical outcomes in direct pulp capping procedure when compared to calcium hydroxide.

Conclusion:

This review confirms that direct pulp capping is an effective conservative approach to maintain the vitality of dental pulp tissue. Qualitative consensus of the research confirmed that MTA showed a higher success rate, reduced pulpal inflammation, and had a more reparative dentin formation when used for direct pulp capping. Calcium hydroxide showed more failures compared to MTA, and the superiority of MTA was confirmed in short and long periods of follow up.

Key words: Pulp capping, dental Pulp Capping, direct pulp capping, evidence-based dentistry, Calcium Hydroxide, Dycal, Ca(OH)2, Mineral Trioxide Aggregate, MTA, GMTA, WMTA and ProRoot MTA.

This study is integrating translational research and translational effectiveness, the two fundamental components of translational science. It focuses to identify a new panel of biological markers for temporomandibular joint disorders (TMJD) by characterizing certain TMJD associated inflammatory, neuroendcrine and tissue destruction biomarkers. In parallel, an evidence-based research synthesis protocol is performed to uncover and evaluate the best available recommendations for treatment interventions associated with the identified TMJD biomarkers. This study is unconventional because the identified biomarkers have never been studied in the same context and combination in TMJD and associated neurological pathologies. This study is positioned at the cutting edge domain of bio-clinical research, and its focus and intent is patient-centered translational research and effectiveness where the patient's health and well being is at the center of importance. Literature study and clinical studies have shown that subconscious stress related behaviors such as Bruxism (clenching and grinding) as well as jaw related trauma could change the jaw bite and decrease its vertical dimension. This will result in bone loss and subsequent irritation and compression of the trigeminal nerve (jaw nerve) leading to local and systemic inflammation and numerous symptoms and pathologies through the central nervous system (CNS), which could be detected by elevation of certain immune, pain and tissue destruction biomarkers in synovial fluid and saliva. The resulting inflammatory response is controlled in part by a bidirectional communication between the brain and the immune systems. It involves hormonal and neuronal mechanisms by which the brain regulates the function of the immune system. Cytokines on the other hand, allow the immune system to regulate the brain. The results of this study demonstrate that TMJD provides a satisfactory model to characterize proteomic biomarker signatures and that it can perhaps be used as a diagnostic tool for early detection, prevention and treatment of TMJD and certain associated neurological pathologies. The results of the research synthesis protocol obtained the best available recommendations for treatment interventions associated with the identified TMJD biomarkers that can be used in the future to conduct a clinical trial.

Introduction and Objective: Dentin Hypersensitivity (DH) is one of the common oral conditions that affect adult population and defined as a short, sharp pain arising from exposed dentin in response to stimuli typically thermal, evaporative, tactile, osmotic or chemical and cannot ascribe to any other form of dental pathology or disease. DH development through two distinct but interrelated phases of tooth wear and gingival recession associated with different etiological factors.

Morphological alterations in DH and intradental nerve excitability are the underlying sources that lead to disease progression, pain evocation as well as therapeutic strategies investigations to interrupt pain transmission. Numerous treatment modalities have been used to manage DH. The interventions of DH have been classified based on the mode of delivery (in-office or professionally-applied therapy and over-the-counter (OTC) or at- home therapy). The other classification used based on the mechanism of action and could be divided into two main categories: the dentinal tubules occluding agents to block the hydrodynamic mechanism of pain stimulation and the nerve desensitizers to interrupt the neural response to pain stimuli (neural blocker). The main objective for any dentine-desensitizing agent is to produce a clinically significant reduction in clinical symptoms and minimize or abolish the symptoms of pain or discomfort associated with DH. The variety of products and techniques used for the treatment of DH indicated a doubt among dentists about the best treatment option, as well as dissatisfaction with outcomes of available treatments, which necessitate the conduction of a comparative effectiveness research and a practice analysis to provide dentists and patients with precise scientific information for comparing the effectiveness and safety of alternative treatment options in resolving DH among different available treatment. The aim of the study is to conduct a comparative effectiveness research to find out if In-office desensitizing agents with dentinal tubules occlusion mechanism of action are more effective than self-applied desensitizing toothpaste with a neural stimulus blocker mechanism of action in resolving dentin hypersensitivity.

Methods: Search for systematic reviews, randomized clinical trials and observational studies were done using the National Library of Medicine-PubMed, Cochrane’s library and the American Dental Association (ADA) web Library. The relevance of the identified systematic reviews, clinical trials and observational studies to the study and PICOTS question was assessed using the inclusion and exclusion criteria. The quality of evidence and clinical relevance analysis achieved using validated and reliable instruments by two independent readers, and all disagreements resolved by discussion after establishing the inter-rater reliability of the two readers. The revised Assessment of Multiple Systematic Reviews (R-AMSTAR) instrument utilized to assess and quantify the quality of retained systematic reviews, the quantified Risk of Bias instrument utilized to evaluate the quality of retained clinical trials and the Expansion in the Grading of Recommendations Assessment, Development and Evaluation (Ex-GRADE) was used to evaluate the clinical relevance and the strength of recommendation. Acceptable sampling analysis was done using the Friedman test statistics. Meta-analysis was done on the two highest quality and homogenous clinical trials.

Results: Three out of six systematic reviews were considered as high-quality studies and two out of thirty-one clinical trials were considered as high-quality studies. However, the bibliome was concerned with a body of literature that has a considerable heterogeneity in terms of quality of the evidence, which prevented further work toward establishing the quantitative and qualitative consensus of the best evidence. Therefore, an alternative approach for acceptable sampling was conducted. Whereby the top 20% highest scoring papers in the bibliome were accepted. So, out of thirty-one studies, seven studies included and considered as high-quality studies. The results of the qualitative analysis of this review shows that 5% potassium nitrate toothpaste has inferior effectiveness in DH management as at home intervention, however, the reduction in the hypersensitivity increase with each recall that suggests the slow effectiveness that could be explained by the requisite of maintaining a high level of potassium nitrate to reach the maximum effectiveness. 5% potassium was not effective compared to in-office desensitizing intervention. Although it is difficult to prove or reach a conclusive evidence of the best treatment option, treatment approaches with resin-based composite restoration and glass ionomer liner resulted in statistically significant reduction in sensitivity. Yet, the complicated procedure of application of these restorations might be considered in terms of time and cost in treating dentin hypersensitivity. Furthermore, it considered as technique sensitive owing to the tendency to perform an overhang at the gingival margins, which contribute to the development of gingivitis or jeopardize the biological width of the periodontal tissues. Gluma and fluoride varnishes were effective in reducing DH for up to 6 months with no reported adverse effects aside to the time and cost consideration.

Conclusion: Based on the qualitative analysis of this review, the 5% potassium nitrate toothpaste has inferior effectiveness in DH management as at home intervention, which was not effective compared to in-office desensitizing interventions. Resin-based composite restoration and glass ionomer liner as in-office interventions yielded statistically significant reduction in sensitivity. However, the complicated procedure of application of these restorations might be considered in terms of time and cost in treating dentin hypersensitivity, which suggest that Gluma and fluoride varnishes might be superior treatment options in reducing DH in terms of efficacy and effectiveness. This review highlights the extent of heterogeneity and quality inferiority of clinical trials in this field, which impact the degree of their reliability. Also, it necessitates the future conduction of well-constructed clinical trials that directed to overcome current deficiencies and weaknesses.

Introduction and objective:

Non-carious cervical lesions (NCCLs) are a very interesting topic in the field of restorative dentistry. This is for several reasons: (1) It considered one of the most common lesions in the permanent teeth. (2) The best restorative materials indicated for NCCLs is still a controversial subject, and (3) despite many studies done and still ongoing, there are no consensuses about bonding agent systems and their bounding effectiveness.

Currently, the restorative options for cervical lesions (in general) are composite resin, glass ionomer, gold foil, and amalgam. Each of these options have different characteristics and properties. For example, gold foil is one of the best dental materials with respect to the physical properties; however, for conservative and esthetic reasons, composite is one of the best restorative dental materials. Glass ionomer comes after composite as an esthetic direct restorative material. Besides this, glass ionomer uniquely has an anti-carious property by releasing fluoride ions. In advanced NCCLs, since the tooth already lost part of its structure, it is preferred to restore these cases with restorations that do not require further preparation for retention like composite resin and glass ionomer. Consequently, composite and glass ionomer are favored over amalgam and gold foil for esthetic and conservative purposes in NCCLs cases. Hence, in this study, we want to compare composite resin and glass ionomer as a restoration option for non-carious cervical lesions (NCCLs). More specifically, we want to evaluate the marginal integrity and retention rate of composite resin and glass ionomer materials as a restoration option for NCCLs.

The aim of this study is to sum up the evidence from multiple systematic reviews, clinical trials, and observational studies that have evaluated the marginal integrity of resin composite and glass ionomer restorations placed in non-carious cervical lesions. In other words, our purpose is to compare glass ionomer and resin composite as restoration for non-carious cervical lesions using an evidence based dentistry approach by going through the Comparative Effectiveness and Efficacy Research and Analysis for Practice (CEERAP) in order to find out which one of these two materials has better marginal integrity.

Methods:

Systematic reviews with or without meta-analysis, observational studies, and randomized clinical trials that assess the effectiveness of glass ionomer, composite resin, and/or adhesive systems, such as a restorative material for NCCLs were chosen. Cochrane library, PubMed, ADA Center for Evidence-Based Dentistry, Google Scholar, Web of Science databases were searched from September 2015 to April 2016. The review was restricted to papers with English language and papers studying permanent teeth with a time frame of no less than one year.

Results:

Three clinical trials and three systematic reviews have been accepted as papers with a high level quality of evidence. All of the accepted clinical trials concluded that glass ionomers have better marginal integrity than resin composite in the NCCLs. On the other hand, two of the systematic reviews agreed with our clinical trials- that glass ionomers as a restoration for NCCLs would have better marginal integrity than resin composite. Only one systematic review concluded that resin composite as a restoration for NCCLs has better marginal integrity than glass ionomer.

Clinical Relevance:

There is a consensus that NCCLs are a multifactorial lesion, caused by abrasive-erosive-ablative stress; hence the resulting dentine is a hyper-mineralized sclerotic dentine with partial or total obliteration of the tubules. The sclerotic dentine phenomenon is shown in Figure (1), which negatively affects dentine bonding. Malocclusion and/or eccentric movements might contribute in initiating or worsening NCCLs. Flexure at the cervical region caused by parafunctional forces has been thought to be one of the etiological factors in NCCLs as well.

Unlike teeth with normal dentine, restoring teeth with sclerotic dentine by composite resin is unpredictable because sclerotic dentine differs anatomically and may need to be etched differently than sound dentin. Consequently, retention, marginal integrity, recurrent caries, micro-leakage, or sensitivity issues are usually shown in NCCLs restored with resin composite.

Key words: Composite - Glass ionomer - NCCLs - Bonding - retention - Marginal discoloration - Marginal integrity.

Introduction and Objective: Peri-implant mucositis is a very common condition affecting the gingival tissue around dental implants. It is an inflammation of the tissues, characterized by bleeding on probing around the implant. This condition is the initial step of a more severe condition called peri-implantitis, which is very difficult to treat. With increased number of implant placements in patients, the length of time each dental implant is supposed to serve, and the price of replacing the implant after failure, the importance of maintaining a healthy tissue around implants has become a fundamental issue. Mechanical debridement is the proposed treatment of peri-implant mucositis, which may be accompanied by adjunctive methods to increase the efficacy of treatment. These options include but are not limited to photodynamic therapy, chlorhexidine, antibiotics, etc.

Due to the importance and prevalence of peri-implant mucositis, the establishment of a treatment protocol is called for. If the addition of adjunctive treatments reduces the inflammation, they can be added to the mechanical debridement approach. Since there are multiple adjunctive methods, there is a need to conduct a comparative effectiveness research to provide scientific information regarding the best option. The aim of this study is to find out whether addition of adjunctive methods to mechanical debridement improves the results of controlling peri-implant mucositis. This improvement can be measured by bleeding on probing scores before and after the intervention.

Methods: Search for systematic reviews, observational studies, and randomized clinical trials studies was done using the National Library of Medicine-PubMed, Cochrane library, the American Dental Association (ADA) web Library, and hand search. The relevance of the identified systematic reviews and clinical trials studies to the study and PICOTS questions was assessed using the inclusion and exclusion criteria. The quality of evidence was achieved using the CONSORT-2010 checklist instrument.

Results: Three out of five randomized clinical trials were considered as high quality studies. We were unable to perform a Meta-analysis due to the heterogeneity in the methods and results of the retained articles.

Conclusion: Based on the results of the three retained randomized clinical trials, chlorhexidine might or might not reduce the bleeding on probing scores around dental implants and antibiotics showed no short term differences.