Science & Women's Resources

Nov. 1, 2004
Systematic Reviews: Review and Keep Asking, 'So What?'

ORAL HEALTH

Systematic Reviews: Review and Keep Asking, ‘So What?’

Systematic reviews are becoming the norm for today’s evidence-based dentistry. Dusting off that research methodology textbook isn’t a bad idea, and here are some quick summaries about those methods.

First, don’t be intimidated by review teams, such as the Cochrane Collaboration, who have rigorous inclusion criteria for studies. Just find out about which criteria are used and think about how the conclusions of these reviews can be incorporated into your practice. Unfortunately, the follow-up period for many dental studies is low, and behavioral research on patients is a nascent topic for dentistry. Here are some simple facts for thinking about systematic reviews and what they could mean for your practice.

1. Note the criteria for inclusion in the review. It should be specified. How are the criteria ranked, and what years of publication are included in the criteria?

2. Assess the design of studies to be included, as well as the time frame. How long is the review period? Many of the most recent studies are not likely to be included in systematic reviews. Be sure to note the follow-up periods. For most dental studies, it is often less than three months, and that is not enough time to assess caries or periodontal disease or even most oral mucosal changes.

3. How were the studies assessed for the review? Were they ranked by methodology or study design? Were the studies ranked by how well-designed the study was or how rigorously the study was conducted? If there were design problems, methodological flaws, or lack of statistical power, how was that addressed in the review? Were the studies ranked numerically by different criteria, such as type of outcome, number of participants, power of study, or statistical significance?

4. Were the protection of human subjects and ethics adherence part of the inclusion criteria for the review?

5. Were financial interests, if any, of the authors disclosed in the articles?

After analyzing a review, ask yourself, “So what? What significance does this have for my practice?” Then, decide how you can incorporate this information into the clinical aspects of your practice.

Study Design Issues To Consider

The following hierarchy of quality study designs may be useful in evaluating systematic reviews:

The gold standard: These are prospective randomized controlled trials in which participants are assigned randomly 1. to a study group receiving a treatment or 2. to a control group receiving a standard treatment or placebo. Randomization limits many confounding factors that could influence the outcome of the study. In a blinded trial, the investigators, the subjects, or both (double-blind study) are not told which is the study group. Dental research has been so poorly funded that there are few prospective evaluations, and large prospective medical trials often don’t include any oral health component.

The silver standard: A cohort study assesses participants who have already been exposed to the risk factor or intervention. Controls that have not been exposed are selected by the researchers to be studied over time. Correcting for confounding variables is key with these studies, often through identifying those confounders and clever use of statistics. Both cohort studies and clinical trials are prospectively designed, requiring large sample sizes and years of observation for sufficient study power to measure differences in outcome. Larger sample sizes and lengthy follow-up periods are often unnecessary in case-control studies.

Copper standards, the case control: Case-control studies can be much smaller, with selection based on whether someone has the disease (e.g., caries), rather than whether he/she has been exposed to a risk factor (e.g., sugar) or clinical intervention (e.g., fluoride). These studies have the disadvantage of being retrospective rather than prospective. Both case-control and cohort studies may have selection biases, because study participants may be different than the general population. These studies may not address the demographics of your particular patient population.

Assess for yourself the value of case reports: Case reports can provide useful information, but barely rank ahead of expert opinion in systematic reviews. They may be subjective and do not generally provide sufficient evidence on which to base clinical practice. They can be useful, however, in designing research questions for larger studies. Don’t rely on case reports to make major changes in your practice.

Expert opinion could be only an anecdote: Many reviews contain significant expert opinion, but not your expert opinion. Note who the expert is, his/her clinical experience, and how his/her practice is similar or different from yours. If expert opinion or novel research approaches are used, remember that those “experts” may not understand today’s approaches to practice or the reality of a woman-owned practice.

Finally, don’t be intimidated by the review teams. Chances are if the criteria are not specified and you can’t understand a systematic review, something is wrong. Use your womanly intuition to see if it meets the “smell test” for common sense, as well as your background in scientific approaches. Read what the review teams say, and then decide for yourself!

New Research on Biomarkers in Saliva for Detecting Periodontal Disease

Gingival crevicular fluid may have just the right stuff, or protein biomarkers, associated with destruction of bone. The State University of New York at Buffalo is examining saliva samples for the same biomarkers to determine if sufficient sample sizes can be obtained. This could lead to a one-step, in-office saliva test to determine active bone loss phases of periodontal disease. Saliva samples will be collected from the University’s UB Women’s Health Initiative Vanguard Center, a five-year prospective study among participating women, with baseline and follow-up oral health data and periodontal status.

WOMEN'S SELF-CARE

Women’s Business Networking

Networking with other women may be the key to success for women dentists who want to dramatically grow their practices. The Women’s Leadership Exchange (WLE) offers regional conferences to support women in entrepreneurial leadership. As a multimedia company founded by and for female entrepreneurs, WLE’s mission is to develop more women leaders in business and other areas of human endeavor by connecting women with top business experts, corporate leaders, and each other. To sign up for an e-newsletter, find out about regional conferences, and more, visit www.womensleadershipexchange.com.

KUDOS!

... to all the women who submitted entries for the Extreme Practice Makeover for their bravery, candor, and honesty. Each of you deserves an award for self-assessment, attention to detail, and honor for wanting the best!

... towomen leaders in dentistry - especially our dental “grandmothers” - who show us how to give back through our practices. Dr. Mary Lynn Morgan, a graduate of Atlanta-Southern Dental College (which later became the Emory University School of Dentistry), developed a pediatric dentistry practice from 1947 until 1976. She received the “Man of the Year” award from the local Georgia Dental Society in the early 1990s. Despite Emory’s dental school closing in the 1990s, the annual lecture on women in the health professions continues there, with a talk given on Oct. 6 by CDC Director Dr. Julie Gerberding.

- UPCOMING CONFERENCES -

OSAP (Organization for Safety and Asepsis Procedures) and the Air Force, Army, Navy, Public Health Service and Veterans Administration - 4th Annual Intermediate-Level Infection-Control and Occupational Safety and Health Course; Jan. 24-27, 2005; Atlanta, Ga.; www.osap.org/training/courses/fsdic/; (800) 298-6727

Yankee Dental Congress (Mass. Dental Society) - Jan. 27-30, 2005; Hynes Convention Center; Boston, Mass.; www.yankeedental.com; (508) 480-9797

CDS (Chicago Midwinter Dental Meeting) - Feb. 24-27, 2005; McCormick Place Lakeside Center; Chicago, Ill.; www.cds.org; (312) 836-7300

Resources To Give Back in Dentistry

With more than 80 percent of the world’s population never seeing a dentist, consider giving back as part of your 2005 business plan for improving oral health in your community and around the world. Here are some resources:

• Health Volunteers Overseas - (202) 296-0928, [email protected], www.hvousa.org.

• Rotary International - (847) 866-3000, http://www.rotary.org/

• Academy of Dentistry International - (419) 542-0101, [email protected]

• Peace Corps - (800) 424-8580

• Children’s Dental Health Month, Feb. 2005 - Community/school activities - www.ada.org/public/news/ncdhm/index.asp#fun

• Give Kids a Smile, Feb. 4, 2005 - www.ada.org/prof/events/featured/gkas/index.asp

Spa Resorts for the Busy Woman Professional

For a treat once the busy holiday and tax season is over, consider visiting a spa with all the extras. Use this time to ascertain whether you want to add more spa amenities to your practice. Check with your accountant about tax breaks.

• La Costa - www.lacosta.com

• Canyon Ranch - www.canyonranch.com

• Rancho La Puerta - www.rancholapuerta.com

• Little Palm Island Resort & Spa - www.littlepalmisland.com

• Daufuskie Island Resort & Breathe Spa- www.breathespa.com

• Golden Door - www.goldendoor.com