Fluoride Varnish for Caries Prevention:Efficacy and Implementation

Many reviews support fluoride varnish (FV) as a caries-inhibitory agent. Evidence from 6 Cochrane systematic reviews involving 200 trials and more than 80,000 participants further confirms the effectiveness of FV, applied professionally 2-4 times a year, for preventing dental caries in both primary and permanent teeth. The relative benefit of FV application seems to occur irrespective of baseline caries risk, baseline caries severity, background exposure to fluorides, use of fluoride toothpaste and application features such as prior prophylaxis, concentration of fluoride or frequency of application. While the efficacy of FV is acknowledged in clinical practice guidelines globally, the implementation of this recommendation may still be an issue. Factors that may facilitate FV application in the USA include Medicaid eligibility, relationships with dentists/community centers and strong cooperation and communication between physicians and support staff. Barriers include insufficient time to integrate oral health services into well-child visits, difficulty in applying FV (lack of skills/training) and resistance among colleagues and staff. Research in the UK/Scotland also suggests encouraging clinicians in their motivation to perform this treatment and addressing professional and parental concerns relating to possible negative consequences may be influential. Further research targeting cost-effectiveness and how FV in routine care may fit in with political agendas relating to, for example, inequalities in health care provision and access will also play a key part in stakeholder decisions to put resources into this issue.</jats:p

Interventions for treating oral mucositis for patients with cancer receiving treatment

Background Treatment of cancer is increasingly effective but is associated with short and long term side effects. Oral and gastrointestinal side effects, including oral candidiasis, remain a major source of illness despite the use of a variety of agents to treat them. Objectives To assess the effectiveness of interventions for the treatment of oral candidiasis for patients with cancer receiving chemotherapy or radiotherapy or both. Search strategy Computerised searches of Cochrane Oral Health Group and PaPaS Trials Registers (to 1 June 2010), CENTRAL via the Cochrane Library (Issue 2, 2010, 1 June 2010), MEDLINE via OVID (1 June 2010), EMBASE via OVID (1 June 2010), CINAHL via EBSCO (1 June 2010), CANCERLIT via PubMed (1 June 2010), OpenSIGLE (1 June 2010) and LILACS via Virtual Health Library (1 June 2010) were undertaken. Reference lists fromrelevant articles were searched and the authors of eligible trials were contacted to identify trials and obtain additional information. Selection criteria All randomised controlled trials comparing agents prescribed to treat oral candidiasis in people receiving chemotherapy or radiotherapy for cancer. The outcomes were eradication of oral candidiasis, dysphagia, systemic infection, amount of analgesia, length of hospitalisation, cost and patient quality of life. Data collection and analysis Data were independently extracted, in duplicate, by two review authors. Trial authors were contacted for details of randomisation and withdrawals and a quality assessment was carried out. Risk ratios (RR) were calculated using fixed-effect models. Main results Ten trials involving 940 patients, satisfied the inclusion criteria and are included in this review. Drugs absorbed from the gastrointestinal (GI) tract were beneficial in eradication of oral candidiasis compared with drugs not absorbed from the GI tract (three trials: RR = 1.29, 95% confidence interval (CI) 1.09 to 1.52), however there was significant heterogeneity. A drug absorbed from the GI tract, ketoconazole, wasmore beneficial than placebo in eradicating oral candidiasis (one trial: RR = 3.61, 95% CI 1.47 to 8.88). Clotrimazole, at a higher dose of 50 mg was more effective than a lower 10 mg dose in eradicating oral candidiasis, when assessed mycologically (one trial: RR = 2.00, 95% CI 1.11 to 3.60). Only one of the ten trials was assessed as at low risk of bias. Authors' conclusions There is insufficient evidence to claimor refute a benefit for any antifungal agent in treating candidiasis. Further well designed, placebo-controlled trials assessing the effectiveness of old and new interventions for treating oral candidiasis are needed. Clinicians need to make a decision on whether to prevent or treat oral candidiasis in patients receiving treatment for cancer. This review is published as a Cochrane Review in the Cochrane Database of Systematic Reviews 2010, Issue 7. Cochrane Reviews are regularly updated as new evidence emerges and in response to comments and criticisms, and the Cochrane Database of Systematic Reviews should be consulted for the most recent version of the Review.</p

Three behavior change theory–informed randomized studies within a trial to improve response rates to trial postal questionnaires

IQuaD was funded by the NIHR HTA (project 09/01/45). INTERVAL was funded by the NIHR HTA (project 06/35/99). No additional funding was obtained to conduct the randomised studies with the trials. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health. The Health Services Research Unit is funded by the Chief Scientist Office of the Scottish Government Health and Social Care Directorates.Peer reviewedPostprin

Interventions for preventing oral mucositis for patients with cancer receiving treatment

Background: Treatment of cancer with chemotherapy is becoming increasingly more effective but is associated with short and long-term side effects. Oral side effects remain a major source of illness despite the use of a variety of agents to prevent them. Objectives: To evaluate the effectiveness of oral (and topical) prophylactic agents for oral mucositis and oral candidiasis in patients with cancer (excluding head and neck cancer), compared with placebo or no treatment. Search Strategy: Computerised MEDLINE, EMBASE, CINAHL, CANCERLIT, the Cochrane Controlled Trials Register and the Cochrane Oral Health Group Specialist Register search up to July 1999. Reference lists from relevant articles were scanned and the authors of eligible studies were contacted to identify trials and obtain additional information. Selection Criteria: Studies were selected if they met the following criteria: design - random or quasi-random allocation of participants; participants - anyone with cancer receiving chemotherapy (excluding head and neck cancer); interventions - prophylactic agents prescribed to reduce oral conditions arising from cancer or its treatment; outcomes - mucositis and oral candidiasis. Data Collection and Analysis: Information regarding methods, participants, interventions and outcome measures and results were independently extracted, in duplicate, by two reviewers (JC &amp; HW). Specialist advice was sought to categorise interventions. Authors were contacted for details of randomisation and withdrawals and a quality assessment was carried out using the Jadad criteria (Jadad 1998). The Cochrane Oral Health Group statistical guidelines were followed and relative risk values calculated using random effects models where significant heterogeneity was detected (P &lt; 0.1). Main Results: Thirty-eight reports of trials were initially included. Two were duplicate reports and nine were excluded as there was no useable information. Of the 27 useable studies 14 had data for mucositis comprising 945 randomised patients and 15 included data for oral candidiasis with 1164 randomised patients. Of the eight prophylactic agents used for mucositis only one, ice chips, was effective (Relative risk 0.57, 95% CI 0.43 to 0.77, chi-square for heterogeneity = 0.26 (df = 1), p = 0.61). The NNT to prevent one extra case of mucositis over the baseline incidence using ice chips was 4 (95%CI: 3 to 7). The NNT for when the baseline incidence of mucositis in the population ranges from 50% to 80% are 5 to 4 respectively. There is evidence that antifungal agents which are partially or fully absorbed from the gastrointestinal tract prevent oral candidiasis and that the partially absorbed agents may be more effective than the fully absorbed agents. The RR for partially absorbed agents was 0.13 (95% CI 0.06 to 0.27, chi-square for heterogeneity = 5.3 (df = 3), P = 0. 15). The NNT to prevent one extra case of oral candidiasis over the baseline incidence using partially absorbed drugs was 3 (95% CI: 3 to 5). The NNT for when the baseline incidence of oral candidiasis in the population ranges from 30% to 70% are 4 to 2 respectively. The general reporting of RCT's was poor however the median Jadad score was acceptable and improved further when the authors provided additional information. The sensitivity analysis confirmed the findings for oral candidiasis. Reviewer's Conclusions: There is some evidence that ice chips prevent mucositis. None of the other prophylactic agents included in this review prevented mucositis. There is evidence that prophylactic use of antifungal agents which are absorbed or partially absorbed from the gastrointestinal tract reduce the clinical signs of oral candidiasis, and the partially absorbed drugs may be more effective. Future trials in this area should address the link between oral and general health including outcomes relevant to the patient. Collaboration between medical and dental teams is indicated.</p

Audit and feedback with or without training in-practice targeting antibiotic prescribing (TiPTAP):a study protocol of a cluster randomised trial in dental primary care

Acknowledgements The authors would like to thank all the dentists and dental team members who are participating in the TiPTAP Trial, as well as the wider QliPT who will ensure the delivery of the intervention. Sponsorship NHS Education for Scotland is the sponsor for the study. NHS Education Scotland will have no role in the design, conduct and analysis of the trial. Funding The study is funded by NHS Education for Scotland.Peer reviewedPublisher PD