MedAbroad Info

 John Hopkins has notified to FDA about the substantial increase (72% of subjects as compared to placebo) in the cardiac events and arrhythmia (irregular heart beats) for the patients that are undergoing Chantix (Verniciline) therapy. Chantix is a prescription drug that helps people to quit smoking.


Smoking is a key culprit in causing heart related events and stopping smoking should actually reduce your chances of such harm. But,
one of the studies by John Hopkins, funded by NCI (National Cancer Institute ) actually showed that Chantix caused an increase in number of heart events even though patients had NO cardiac (heart) symptoms to begin with.

The drug does mention that there are possible heart related events possible for those people who already have heart disease. As Dr. Singh says, now the whole idea of prescribing Chantix has a new twist and should measure the "risk-benefit ratio"

“People want to quit smoking to reduce the risk of cardiovascular disease but in this case they’re taking a drug that increases the risk for the very problems they’re trying to avoid,” says Sonal Singh, M.D., M.P.H., an assistant professor of general internal medicine at the Johns Hopkins University School of Medicine and the lead author of the research.  
source

Let me all introduce you to one of the champions of EBD, Evidence Based Dentistry, Hope Saltmarsh. She is one of the very few people who have been trained in EBD and is working in EBD arena since its inception.

Let me introduce you to Hope Saltmarsh.


This interview in TWO part series will talk in depth about basics of EBD through her real experiences
I would let her say more than me speaking about her. 



Hello Ms. Hope!!


Hello people, My name is Hope Saltmarsh.

Ms. Hope Salthmarsh

A few years after graduating from college with a degree in biology, when my children had started school, I attended a local community college to earn an associates degree in dental hygiene. I worked for many years in private practice before accepting a full-time position developing, delivering and later directing a school-based dental program. The program is now the largest in NH serving 21 elementary schools with a staff of 4 and with over 20 area dentists volunteering their time to screen or treat students.




Since 2003, I have been educating medical providers in NH about integrating oral health into primary practice especially for children 0-3 yrs. old. At the outset, using Pubmed I did a literature search on early childhood caries. I gave the studies I’d gathered to the physician I was working with and he graded the evidence. He informed me that the evidence was not of a very high quality. That was the beginning of a journey that has led me to becoming an evidence reviewer for the ADA and an EBD champion.


I had been quite enthused about the information that I found and it was disappointing for me to have some of the studies I was most interested in dismissed because of their low level of evidence. What a novel idea – some evidence is much better than other evidence and there is a way to judge the level!!
I learned that there are different levels of evidence based on their design. (To illustrate) Picture a pyramid with systematic reviews at the top and expert opinion and animal or in vitro research at the bottom. In between are various types of individual studies of varying strength. The evidence on the upper parts of the pyramid are stronger than the evidence at the bottom. For any given clinical question, you will find evidence that falls somewhere within the pyramid. You can sort through it to find the highest quality evidence by using the pyramid. That is the first step. You need to understand how to appraise the evidence to further distinguish quality, because not all systematic reviews are equally well-done, for instance.

ADA's EBD course participants at Forsyth Oct. 2009 with Hope in third Row

A few years ago, I attended a continuing education course on Evidence-based Dentistry presented by Dr. Richard Neiderman, Director of Forsyth Institute Center for Evidence-based Dentistry. I was interested in the content of the course, but certainly not excited. It really isn’t a very exciting topic until you have a specific application for the evidence you seek. During the presentation, Dr. Neiderman made a reference to a school-based program he was involved with. That caught my attention so I went up to talk to him after the program to learn more about it. I was immediately very interested because using the same equipment in the same kind of setting that I had been working for years, I learned that the ForsythKids program was delivering much more to children than our program did.




The school-program I direct has now adopted many of those evidence based practices for which has been a significant benefit to the children we serve and to the dentists who work with us along with our funders. We visit each school twice a year, our volunteer dentists assess each child, and eligible children are able to receive a cleaning, sealants and/or temporary fillings applied with ART (Atraumatic Restorative Techniques) using glass ionomer cement, and fluoride varnish. This takes us no longer than it used to take us to provide a cleaning, sealants and fluoride varnish just once a year. Using an evidence-based approach to deliver our program as opposed to just looking at what everyone else is doing and adopting those practices has significantly increased the value we give to our patients. This is so important because our patients are at high risk for decay and they have poor access to treatment.




Last year, when I read an announcement of the ADA’s week-long Evidence-based Dentistry (EBD) course offered at Forsyth Institute, I quickly applied. I am so glad that I was accepted to join about 30 others with such diverse backgrounds. Most were from the US, but there were several from South America, a dentist from Russia and another from Egypt. Many were academics there to learn more about EBD to take that back to their schools to train faculty and students.


I also met someone from an insurance company, research, a journal editor and a reporter, as well as several from private practice in various specialties. Our primary instructors were Derek Richards, the Director of the Centre for Evidence-based Dentistry at Oxford University (UK), editor of the Evidence-based Dentistry Journal and Richard Neiderman.




The course was part lecture and part smaller discussion groups. We were required to do reading prior to the course and every evening we had to read and appraise studies for discussion the next day. The discussions were so interesting because of the depth of experience and variety of backgrounds represented. It was a challenging, exhausting and exhilarating week. It was a wonderful experience and I would strongly recommend it to others.


If a clinician wishes to provide the best treatment for patients, it will be necessary to know how to keep up with the enormous flow of new information and to have the knowledge needed to pick out the best, most applicable pieces of evidence to use in treating individual patients. The technology at our fingertips makes it possible to do this fairly easily and quickly IF the clinician is well-versed in EBD. Dentistry is based on science and science changes. Clinicians need to be able to keep up.
Another practical reason is that when making purchases, we need to be able to ask sales people the right questions and to search out the information that will enable us to spend wisely.




One of the things I learned about was the ADA’s new EBD website: http://ebd.ada.org
This resource, open to everyone, is funded by a grant from National Library of Medicine and the National Institute for Dental and Craniofacial Research. It is a terrific resource for anyone wanting to find more information about EBD with links to a great many quality resources to extend knowledge. The website also has a large collection of systematic reviews on a broad variety of topics. There are also links to many EBD resources. One takes you to Virginia Commonwealth University’s EBD Resources website where your readers can find lots of information to get them started: http://guides.library.vcu.edu/ebd


MedA: Let me add one of my own: http://us.evidentista.org/index.aspx
And http://nature.com/ebd/index.html

Sincere People · Real Experiences · Authentic Info

This interview is the continuation of the TWO part series about Evidence based Dentistry, EBD. Please see the second and the last part about EBD below. (It gets a little more technical here, but very important)

Hello Ms Hope, lets continue about Evidence Based Dentistry.
MedA: We were talking about SR and CS and I feel our readers are not aware of that.  So could you elaborate more on this SR and CS thingi?

Hope: There are different kinds of study designs that provide different strengths of evidence. For example, an expert panel might convene to offer advice about a clinical question. This evidence would not be as strong a design as a randomized controlled trial (RCT). And systematic reviews (SR) provide the highest level of evidence because their authors search for all the evidence they can about a particular clinical question and then analyze all of the relevant studies together, often with a meta-analysis, to give the best overall assessment of the current state of the evidence on that topic. That is why only systematic reviews are collected at the ADA EBD website – they put the highest level of evidence at user’s fingertips.

The systematic reviews are arranged by topic and subtopics. Clicking on any SR takes you to its abstract in PubMed. There is often a link there to the full article, which may or may not be freely accessible in full. Because there are so many different professional journals and most dentists do not have subscriptions to many, a wonderful feature of the EBD website is the posting of critical summaries for a growing number of SRs. If you find a critical summary right beside the SR listing, you can read that 600-800 word document and you will get a summary of the results of the review, the authors’ conclusions and a critique of the strengths and weaknesses of the way the review was conducted and of the strengths and weaknesses of the evidence itself. The critical summary (CS) ends with a description of the clinical implications.

In March 2010, I attended an ADA training to learn to write critical summaries (CS) of systematic reviews (SR) posted at the ADA’s EBD website: http://ebd.ada.com  The critical summaries are intended to help clinicians more quickly access the evidence from the systematic reviews collected at the site. A CS is written in a concise, easy to understand manner. This is a very structured, time-consuming, and demanding process. I can assure you that before a CS appears at the web-site, it has been scrutinized by several experts who look at every word. So far, two of the CS’s I authored have been posted to the website.

MedA: can any one write the CSs? How can I be a part of these CSs?  Could you please elaborate this !!
Hope: Anyone who is interested in writing critical summaries for the ADA can apply at the EBD website. It is a volunteer activity and to be eligible you need to have a “dental degree.” I was eligible as a dental hygienist and I am sure it helped that I had attended the EBD course at Forsyth. Accepted applicants will attend a 2-day training. Per the ADA: “Learn how to put evidence-based information to practical use and contribute your knowledge to the dental profession! Here is a unique opportunity... for educational and professional development under EBD experts, continuing education credit, for publication acknowledgement, and to help colleagues use current evidence in decision-making.” My obligation, after the training, is to write at least 10 critical summaries over the course of 2 years. So far, I have finished two and a third is almost through the process.

MedA: How did you end up with your first CSs?
Hope: I was very excited when the first one was posted – but I really know very few people who could share my excitement. The first one, I co-authored with Ahmed El-Kadem, a dentist and faculty member at Cairo University. We both attended the EBD course last year and then a training to be ADA evidence reviewers. We collaborated online to write our first CS. One of the great benefits of being a reviewer is being assigned an expert mentor. He  worked closely with us to prepare a CS that we could submit to a Critical Review Panel for the next step in the process. Additionally, each issue of the Journal of the American Dental Association now contains one CS.

You can find our critical summary at the ADA’s EBD website: http://ebd.ada.org . Clink on the lower left picture for Systematic Reviews. Ours is under Endodontics, subheading: Outcomes. You will see a list with 3 columns: Systematic Reviews, Critical Summary, Plain Language Summary. Currently, ours is the second SR in this section that has a critical summary. Soon it will also have a plain language summary that will be easily accessible to the public. The title of the Systematic Review we wrote about is:
Single versus multiple visits for endodontic treatment of permanent teeth: a Cochrane systematic review 
Figini L, Lodi G, Gorni F, Gagliani M. Journal of Endodontics. 2008;34(9):1041-7

If you click on that title, you will be taken to the CONCHRANE review. You will notice that to the right of the SR title is “Critical Summary”. Click on that and you will be able to read our critical summary.

MedA What do you think is the future of EBD with respect to students, new dentists and practicing dentists?

Attendees of the March 2010 ADA Evidence Reviewer Workshop at NYU.

 Hope: Dental schools will all soon be making EBD an essential part of dental education so that future dentists will be life-long learners who can find and appraise evidence and keep up with our constantly evolving understanding of dental science. An accreditation standard that will be in effect by July 2013, states “Graduates [of dental schools] must be competent to access, critically appraise, apply, and communicate scientific and lay literature as it relates to providing evidence-based patient care.” Another accreditation standard for US dental schools will be, “Patient care must be evidenced-based, integrating the best research evidence and patient values.”

So dental students in the future, and in some dental schools for students right now, the future will absolutely involve a strong understanding of EBD. For those who have already graduated and for many graduating soon, the decision to practice with an evidence-based approach will be their own. A great effort is being made by the ADA and other organizations to teach EBD and make easily accessed evidence-based resources available. I suspect that online tools will develop to meet the tremendous need for excellent, evidence-based information that can be used by dentists who have never received EBD training. Of course, there are also many wonderful resources available online that anyone can use to teach themselves the basics of EBD – if they are sufficiently motivated to spend the necessary time.

As a caution, the term evidence-based is often used by individuals to indicate something that has some kind of evidence. What we require is the best evidence – much of which is now limited and non-existent.  An increase in demand for more and better evidence will hopefully improve the situation!


MedA: Is EBD actually like a cook book type dentistry? I mean, for every situation, you gotta do this then that followed by that!!
Hope: I attended the very popular EBD Champions Conference in Chicago put on by the ADA. The goal is to give dental professionals from across the US an overview of EBD and teach them how to return to their states and share what they’ve learned with their colleagues. I learned there that there are many dentists who are very uncomfortable with EBD seeing it as a threat to the ability of dentists to provide their patients with personalized, individual care. Many fear that it will lead to practice requirements that every dentist must provide for each patient – cookbook dentistry, as you said. I guess that because I took the EBD course before I became a Champion, I was surprised because I knew that EBD is actually just the opposite. To begin with, the needs of patients will always be extremely individual. Right now, the science of dentistry has little really strong, good evidence. And that evidence applies to the population studied – not all people. Fortunately, the evidence will improve and grow providing more and better evidence to inform the clinical decisions that dentists make. It is, however, only a piece of the decision-making process that clinicians use along with their expertise and experience to meet the needs and preferences of their patients.

You can find a wonderful description of how one dentist used EBD to provide an individual patient the best treatment possible in The Journal of Evidence-based Dental Practice, September 2010 at www.jebdp.com. The feature article, titled Use of evidence-based decision making in private practice for emergency treatment of dental trauma: EB case report  was written by Syrene A. Miller and Greg Miller and appears on pages 135-146. I am sure it will provide you and your readers with a good appreciation for what EBD is and how it could be used in practice.



Sincere People · Real Experiences · Authentic Info

WHEN:  November 1-5, 2010 |
WHERE: Forsyth Institute (Boston, MA)

The ADA Center for Evidence-Based Dentistry is collaborating with The Forsyth Institute (Boston, MA) to offer a new, one-week intensive course on evidence-based dentistry (EBD). The course will take place November 1-5, 2010, at The Forsyth Institute in Boston, Massachusetts.

Based on recent survey data, practicing dentists asked the ADA to offer a formal, intensive EBD course. The ADA/Forsyth EBD Course will link the strong EBD initiatives of the ADA Center for Evidence-Based Dentistry with The Forsyth Institute’s solid history of scientific research.

Who should register

    * The course is relevant to all dentists and members of the dental team, educators, researchers including practitioners involved in practice-based research networks (PBRNs) and other professionals involved in dentistry.
    * The course is open to both US-based and international individuals.

Course details

• The course is a 5-day interactive program that will include a pre-assignment and multiple hands-on activities.
• Attendees will receive CE credits from the ADA and a certificate in EBD from the Forsyth Institute.
• International applicants please note: The course will be offered only in English language; no simultaneous interpretation will be provided. 

Course faculty

• Dr. Richard Niederman (Director, Center for Evidence-Based Dentistry, Forsyth Institute); and
• Dr. Derek Richards (Director, Center for Evidence-Based Dentistry at Oxford University, UK). 

Application process

• All interested candidates must fill out an online questionnaire and submit a current curriculum vitae (CV).
• Applications will be reviewed on a rolling admission process, and up to 30 students will be admitted to the course. All accepted applications will be notified as decisions are made, but no later than September 1, 2010.
• Course tuition is $2,500 (ADA members will receive a 20% discount).
• Participants will be responsible for their travel and housing in Boston.

Contact information

EBD#5 : Is local delivery of tetracycline an effective option in the treatment of chronic periodontitis?

Data sources: Medline provided the primary data source and references lists from the identified papers were reviewed to source additional studies.

Study selection: Studies published in English prior to December 2001 were included if they were primary randomised controlled trials; were conducted in human subjects; examined the effects of local tetracycline in various forms in reducing probing depth (PD) and/or improving attachment level (AL); and they reported mean and measures of variance of PD and AL.

Data extraction and synthesis: The methods and results section of each article were read and scored by two independent readers. Meta-analyses were performed on the basis of baseline PD, type of antibiotic used, and experimental and control regimens. A random-effects model was used to combine data.

Results: A total of 29 studies met the inclusion criteria and were included in the meta-analyses. The quality assessment showed the studies to be of variable quality, with many failing to report relevant information. A significant mean reduction in PD was observed when tetracycline was used as an adjunct to scaling and root planing (SRP; mean difference at 12 weeks, 0.69 mm; 95% confidence interval, 0.57–0.81; P<0.001).>6 mm after 4 (P<0.001) p="0.005)" style="font-weight: bold; color: rgb(0, 153, 0);">Conclusions: The meta-analyses demonstrated that statistically significant, although not clinically substantial, improvement could be achieved in cases of chronic periodontitis when local delivery of tetracycline was used as an adjunct to scaling and root planing.


I would personally recommend to read Commentary for the above section

Q EBD# 4: In type-1 diabetics, is nonsurgical periodontal treatment with adjunctive doxycycline more effective than nonsurgical periodontal treatment alone?

Design

This was a randomised controlled trial (RCT).

Intervention

Group 1 (30 patients) was given oral-hygiene instruction, scaling and root planing, chlorhexidine rinses twice a day and doxycycline (100 mg/day for 15 days). Group 2 (30 patients) had the same treatment but without doxycycline.

Outcome measure

Plaque index (PI), probing pocket depth (PPD), clinical attachment levels (CAL) and bleeding on probing (BOP) were recorded.

Results


Both groups had a measurable improvement in all periodontal parameters, since PI, BOP, PPD and CAL were reduced. The reduction in PPD of 6 mm and in BOP became statistically significant when doxycycline was used (group 1), however.

Conclusions

Although both periodontal treatment regimens are effective in type-1 diabetics, the use of doxycycline as an adjunct provided more significant results when good plaque control was achieved.

EBD#3: Q: What is the correct timing of pulp extirpation for replanted avulsed teeth?


Data Sources


A search was performed (April 2004) across four databases, namely Ovid Medline, Cochrane Library, PubMed and Web of Science, relevant to the proposed PICO ( Patient or problem, Intervention, Comparison, Outcome) question: (P) for a replanted avulsed permanent tooth, (I) is early pulp extirpation within 10–14 days of replantation, (C) compared with delayed pulp extirpation, (O) associated an increased likelihood of successful periodontal healing after tooth replantation. Only articles published in the English language were considered.

Study selection

Relevant titles were selected for abstract assessment (N = 628), and then 84 papers were selected for examination.

Data extraction and synthesis

A quality assessment was made of relevant publications: only six papers met the inclusion criteria (making a total of 236 teeth).

Results

Meta-analysis found a statistically significant association between pulp extirpation performed after 14 days and the development of inflammatory resorption. Pulp extirpation within 10 days of re-plantation was not significantly associated with a decreased likelihood of developing inflammatory resorption. There is no significant difference in pulp extirpation times for functional healing, acceptable healing without progressive resorption, or the development of replacement resorption.

Conclusions

There is clinical evidence for an association between pulp extirpation performed after 14 days following replantation and the development of inflammatory resorption. This investigation supports the current clinical guidelines for pulp extirpation within 10–14 days of replantation.

EBD#2:

Q: Does traumatic intrusion of primary teeth on the permanent successor teeth cause enamel hypoplasia, dilacerations, ectopic eruption?

Ans: Yes it does.. and what all it does.. please do read on..
Design of study: This was a clinical observational study

This was a clinical observational study of primary incisor trauma, in children of under 4 years of age at the time of injury, with a 7-year follow up period.

EBD#1:

Question: Are sublingual vitamin B12 tablets effective in reducing the frequency of recurrent aphthous stomatitis episodes?

A randomized double-blind, placebo-controlled trial done by Volkov I, Rudoy I, Freud T, et al.

Intervention
Panks
POWER OF INFO
Sincere People · Real Experiences · Authentic Info

Under EBD, we will be launching abstracts from reputed Journals on the conditions that we encounter on daily basis. This will help not only the budding students but also the new dentists who are still gaining experience in the REAL world to work more efficiently and confidently.

You might have wondered sometime...

• Does Perio Treatment prevents any undue Pregnancy complications?
• Is Vit B12 an effective treatment fOr Major Aphthous Ulcers?
• What is the perfect timing of Pulp Extirpation for replanted avulased Teeth?