Rational perspectives on risk and certainty for dentistry during the COVID-19 pandemic

Clinical dental practice exposes the dental team and patients to infectious airborne disease agents, due to the close contact during clinical care, and the infectious aerosols from most dental procedures. The U.S. Centers for Disease Control and Prevention (CDC), the American Dental Association (ADA) and other organizations developed recommendations to address the specific risk profile of SARS-CoV-2 transmission, adding additional protective measures to established standard precautions. When deciding on re-opening of dental services it is important to remember that so far, no reliable data on work-related infection risk for dental personnel are available. Combined with other uncertainties it seems prudent to follow four key principles: 1) All patients should be considered as potentially infectious; 2) procedures generating aerosols should be avoided, limited or closely managed; 3) infection control should be increased according to recommendations; 4) PPE measures should be maximized. Dental teams must follow ethical principles in providing the best possible and safe dental care. Yet, as business owners, they are facing existential impacts from reduced patient visits and loss of income resulting from service limitations. Reconciling the conflict of risking their life or their livelihood under the COVID-19 pandemic is not a welcome or easy choice. Decisions must be based on best possible evidence, and need to be revisited as the pandemic, and economic conditions change. COVID-19 also unmasked the challenges of access and financial coverage for dental care in the U.S. Sustainable preparation for future pandemics should consider reforms towards a more equitable system with better coverage

Topical silver diamine fluoride for managing dental caries in children and adults

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To assess the effects of silver diamine fluoride in arresting and preventing caries in deciduous and permanent teeth (coronal and root caries) compared to any other intervention including placebo or no treatment.</p

The methodological quality of systematic reviews comparing temporomandibular joint disorder surgical and non-surgical treatment

<p>Abstract</p> <p>Background</p> <p>Temporomandibular joint disorders (TMJD) are multifactor, complex clinical problems affecting approximately 60–70% of the general population, with considerable controversy about the most effective treatment. For example, reports claim success rates of 70% and 83% for non-surgical and surgical treatment, whereas other reports claim success rates of 40% to 70% for self-improvement without treatment. Therefore, the purpose of this study was to (1) identify systematic reviews comparing temporomandibular joint disorder surgical and non-surgical treatment, (2) evaluate their methodological quality, and (3) evaluate the evidence grade within the systematic reviews.</p> <p>Methods</p> <p>A search strategy was developed and implemented for MEDLINE, Cochrane Library, LILACS, and Brazilian Dentistry Bibliography databases. Inclusion criteria were: systematic reviews (± meta-analysis) comparing surgical and non-surgical TMJD treatment, published in English, Spanish, Portuguese, Italian, or German between the years 1966 and 2007(up to July). Exclusion criteria were: <it>in vitro </it>or animal studies; narrative reviews or editorials or editorial letters; and articles published in other languages. Two investigators independently selected and evaluated systematic reviews. Three different instruments (AMSTAR, OQAQ and CASP) were used to evaluate methodological quality, and the results averaged. The GRADE instrument was used to evaluate the evidence grade within the reviews.</p> <p>Results</p> <p>The search strategy identified 211 reports; of which 2 were systematic reviews meeting inclusion criteria. The first review met 23.5 ± 6.0% and the second met 77.5 ± 12.8% of the methodological quality criteria (mean ± sd). In these systematic reviews between 9 and 15% of the trials were graded as high quality, and 2 and 8% of the total number of patients were involved in these studies.</p> <p>Conclusion</p> <p>The results indicate that in spite of the widespread impact of TMJD, and the multitude of potential interventions, clinicians have expended sparse attention to systematically implementing clinical trial methodology that would improve validity and reliability of outcome measures. With some 20 years of knowledge of evidence-based healthcare, the meager attention to these issues begins to raise ethical issues about TMJD trial conduct and clinical care.</p

Dental sealant knowledge, opinion, values and practice of Spanish dentists

[Background] Multiple guidelines and systematic reviews recommend sealant use to reduce caries risk. Yet, multiple reports also indicate that sealants are significantly underutilized. This study examined the knowledge, opinions, values, and practice (KOVP) of dentists concerning sealant use in the southwest region of Andalusia, Spain. This is a prelude to the generation of a regional plan for improving children’s oral health in Andalusia.[Methods] The survey’s target population was dentists working in western Andalusia, equally distributed in the provinces of Seville, Cadiz, and Huelva (N=2,047). A convenience sample of meeting participants and meeting participant email lists (N=400) were solicited from the annual course on Community and Pediatric Dentistry. This course is required for all public health sector dentists, and is open to all private sector dentists. Information on the dentist’s KOVP of sealants was collected using four-part questionnaire with 31, 5-point Likert-scaled questions.[Results] The survey population demographics included 190 men (48%) and 206 women (52%) with an average clinical experience of 10.6 (± 8.4) years and 9.3 (± 7.5) years, respectively. A significant sex difference was observed in the distribution of place of work (urban/suburb) (p=0.001), but no sex differences between working sector (public/private). The mean ± SD values for each of the four KOVP sections for pit and fissure sealants were: knowledge = 3.57 ± 0.47; opinion = 2.48 ± 0.47; value = 2.74 ± 0.52; and practice = 3.48 ± 0.50. No sex differences were found in KOVP (all p >0.4). Independent of sex: knowledge statistically differed by years of experience and place of work; opinion statistically differed by years of experience and sector; and practice statistically differed by years of experience and sector. Less experienced dentists tended to have slightly higher scores (~0.25 on a Likert 1–5 scale). Statistically significant correlations were found between knowledge and practice (r=0.44, p=0.00) and between opinion and value (r=0.35, p=0.00).[Conclusions] The results suggest that, similar to other countries, Andalusian dentists know that sealants are effective, have neutral to positive attitudes toward sealants; though, based on epidemiological studies, underuse sealants. Therefore, methods other than classical behavior change (eg: financial or legal mechanisms) will be required to change practice patterns aimed at improving children's oral health.We acknowledge the following sources for invaluable financial support NIMHD 1 R34 DE022272 (NIH2385) and NIDCR 1 U24 MD006964

Future research directions in pneumonia

Copyright © 2018 by the American Thoracic Society. Pneumonia is a complex pulmonary disease in need of new clinical approaches. Although triggered by a pathogen, pneumonia often results from dysregulations of host defense that likely precede infection. The coordinated activities of immune resistance and tissue resilience then dictate whether and how pneumonia progresses or resolves. Inadequate or inappropriate host responses lead to more severe outcomes such as acute respiratory distress syndrome and to organ dysfunction beyond the lungs and over extended time frames after pathogen clearance, some of which increase the risk for subsequent pneumonia. Improved understanding of such host responses will guide the development of novel approaches for preventing and curing pneumonia and for mitigating the subsequent pulmonary and extrapulmonary complications of pneumonia. The NHLBI assembled a working group of extramural investigators to prioritize avenues of host-directed pneumonia research that should yield novel approaches for interrupting the cycle of unhealthy decline caused by pneumonia. This report summarizes the working group’s specific recommendations in the areas of pneumonia susceptibility, host response, and consequences. Overarching goals include the development of more host-focused clinical approaches for preventing and treating pneumonia, the generation of predictive tools (for pneumonia occurrence, severity, and outcome), and the elucidation of mechanisms mediating immune resistance and tissue resilience in the lung. Specific areas of research are highlighted as especially promising for making advances against pneumonia

Updated guidance on the management of COVID-19:from an American Thoracic Society/European Respiratory Society coordinated International Task Force (29 July 2020)

BACKGROUND: Coronavirus disease 2019 (COVID-19) is a disease caused by severe acute respiratory syndrome-coronavirus-2. Consensus suggestions can standardise care, thereby improving outcomes and facilitating future research. METHODS: An International Task Force was composed and agreement regarding courses of action was measured using the Convergence of Opinion on Recommendations and Evidence (CORE) process. 70% agreement was necessary to make a consensus suggestion. RESULTS: The Task Force made consensus suggestions to treat patients with acute COVID-19 pneumonia with remdesivir and dexamethasone but suggested against hydroxychloroquine except in the context of a clinical trial; these are revisions of prior suggestions resulting from the interim publication of several randomised trials. It also suggested that COVID-19 patients with a venous thromboembolic event be treated with therapeutic anticoagulant therapy for 3 months. The Task Force was unable to reach sufficient agreement to yield consensus suggestions for the post-hospital care of COVID-19 survivors. The Task Force fell one vote shy of suggesting routine screening for depression, anxiety and post-traumatic stress disorder. CONCLUSIONS: The Task Force addressed questions related to pharmacotherapy in patients with COVID-19 and the post-hospital care of survivors, yielding several consensus suggestions. Management options for which there is insufficient agreement to formulate a suggestion represent research priorities.status: Published onlin

An evaluation of prescribing practices for community-acquired pneumonia (CAP) in Mongolia

BACKGROUND: Community-acquired pneumonia (CAP) is a significant cause of morbidity and mortality in all age groups worldwide. It may be classified as mild/moderate or severe, the latter usually requiring hospitalisation. Although, there are many studies reported in relation to CAP, there is relatively little known about the treatment of CAP and its antibiotic use in Mongolia. The study aim was to evaluate prescribing practices for the treatment of mild/moderate CAP in Mongolia with respect to national prescribing guidelines. METHODS: Written prescriptions with a written diagnosis of CAP included were collected prospectively and sequentially for ten weeks from a purposefully selected sample of community pharmacies in rural and urban areas of Mongolia. The data collected included the patient's age, gender, medication details, frequency and number of doses prescribed. Evaluation was with respect to the Mongolian Standard Treatment Guidelines (2005, 2008). Statistical differences between groups were tested using the Chi-squared and Fisher's exact tests.RESULTS: Prescriptions were collected from 22 pharmacies and represented the prescribing practices of 118 doctors. The study enrolled 394 (193 adults and 201 children) patients, with a median age for children of 2.0 years (range: 0.03-12) and adults of 33.0 years (range: 13--92).The most commonly prescribed drugs were amino penicillins, vitamins, and mucolytics, with the median number of drugs being three per prescription. Inappropriate drug selection was similar for adults (57.7%) and children (56.6%), and the major reason for an overall frequency of inappropriate prescribing for adults were 89.0% and for children 78.0%. Doctors in urban areas prescribed more inappropriate drugs than those in rural areas for both children and adults, p = .0014. The proportion of prescribed injections was 28.4% for adults and 9.0% for children, and for adults was significantly higher in urban areas. The prescribing standard for non-hospitalized patients in Mongolia states that injections should not be prescribed. CONCLUSIONS: The high level of inappropriate prescribing for mild/moderate CAP highlights the need to develop comprehensive and reliable procedures nationwide to improve prescribing practices in Mongolia

Sicily statement on classification and development of evidence-based practice learning assessment tools

<p>Abstract</p> <p>Background</p> <p>Teaching the steps of evidence-based practice (EBP) has become standard curriculum for health professions at both student and professional levels. Determining the best methods for evaluating EBP learning is hampered by a dearth of valid and practical assessment tools and by the absence of guidelines for classifying the purpose of those that exist. Conceived and developed by delegates of the Fifth International Conference of Evidence-Based Health Care Teachers and Developers, the aim of this statement is to provide guidance for purposeful classification and development of tools to assess EBP learning.</p> <p>Discussion</p> <p>This paper identifies key principles for designing EBP learning assessment tools, recommends a common taxonomy for new and existing tools, and presents the Classification Rubric for EBP Assessment Tools in Education (CREATE) framework for classifying such tools. Recommendations are provided for developers of EBP learning assessments and priorities are suggested for the types of assessments that are needed. Examples place existing EBP assessments into the CREATE framework to demonstrate how a common taxonomy might facilitate purposeful development and use of EBP learning assessment tools.</p> <p>Summary</p> <p><it>The widespread adoption of EBP into professional education requires valid and reliable measures of learning. Limited tools exist with established psychometrics. This international consensus statement strives to provide direction for developers of new EBP learning assessment tools and a framework for classifying the purposes of such tools</it>.</p