Quality Assessment of Systematic Reviews on Periodontal Regeneration in Humans

Background: Systematic reviews represent the highest form of evidence in the current hierarchy of evidence‐based dentistry. Critical analysis of published systematic reviews may help to analyze their strengths and weaknesses and to identify areas that need future improvement. The aim of this overview is to determine and compare the quality of systematic reviews published in the field of periodontal regeneration using established checklists, such as the Assessment of Multiple Systematic Reviews (AMSTAR) guidelines. Methods: A systematic search was conducted to retrieve reviews on periodontal regeneration in humans. A total of 14 systematic reviews were selected using a set of inclusion and exclusion criteria. Two independent reviewers appraised the quality of the selected reviews using AMSTAR guidelines. Each article was given an AMSTAR total score, based on the number of AMSTAR criteria that were fulfilled. The quality of included reviews was further assessed using a checklist proposed in 2003. Results: Only one of the selected systematic reviews satisfied all the AMSTAR guidelines, whereas two reviews satisfied just two of the 11 items. This study shows that published systematic reviews on periodontal regeneration exhibit significant structural and methodologic variability. Quality assessment using the additional checklist further confirmed the variability in the way systematic reviews were conducted and/or reported. Conclusion: Consideration of guidelines for quality assessment, such as AMSTAR, when designing and conducting systematic reviews may increase the validity and clinical applicability of future reviews.     

The association between periodontitis and coronary heart disease: A quality assessment of systematic reviews

BackgroundThe existence of an association between periodontitis and cardiovascular disease has been proposed by investigators in several clinical studies and further confirmed by the results of several systematic reviews. The aim of the Authors' study was to assess the quality of published systematic reviews focused on the association between periodontitis and coronary heart disease (CHD) by using established systematic review assessment checklists.MethodsTwo reviewers conducted a search for systematic reviews focusing on the association between periodontitis and CHD. Three independent reviewers appraised the quality of the selected 13 reviews by using an established and validated assessment tool for systematic reviews and another checklist. They gave each article a total score according to the number of criteria on each checklist that the article fulfilled.ResultsNine reviews satisfied six or more items on the assessment tool, whereas two reviews each satisfied only one item. This assessment shows that published systematic reviews of the periodontitis-CHD association exhibit significant structural and methodological variation, which the authors further confirmed by using the second checklist.ConclusionSystematic reviews of the association between periodontitis and CHD exhibited significant differences in their methodological quality.Practical ImplicationsClinicians should be aware that not all systematic reviews of the periodontitis-CHD association are conducted in a rigorous manner and should be capable of differentiating well-conducted reviews from poorly conducted ones.     

Impact of bisphosphonate therapy on dental implant outcomes: An overview of systematic review evidence

The purpose of this overview was to assess the methods, quality, and outcomes of systematic reviews conducted to evaluate the impact of bisphosphonates on dental implants and the risk of developing bisphosphonate-related osteonecrosis of the jaw after dental implant surgery. An electronic search without date or language restriction was performed in the PubMed/MEDLINE, Cochrane CENTRAL, Web of Science, and LILACS databases (to January 2018). Eligibility criteria included systematic reviews that evaluated the impact of bisphosphonates on implant outcomes. The quality assessment of the included reviews was done using AMSTAR 2 guidelines. The protocol of this overview was registered in PROSPERO (CRD42018089617). The search and selection process yielded seven reviews, published between 2009 and 2017. None of the systematic reviews included in this study obtained the maximum score in the quality assessment. The scientific evidence available demonstrates that patients with a history of bisphosphonate use do not present a higher risk of dental implant failure or marginal bone loss compared to patients who have not used bisphosphonates. The literature also suggests that patients who undergo surgical trauma during the installation of dental implants may be more susceptible to bisphosphonate-related osteonecrosis of the jaw.     

Management of TMD: evidence from systematic reviews and meta‐analyses

Summary This systematic review (SR) synthesises recent evidence and assesses the methodological quality of published SRs in the management of temporomandibular disorders (TMD). A systematic literature search was conducted in the PubMed, Cochrane Library, and Bandolier databases for 1987 to September 2009. Two investigators evaluated the methodological quality of each identified SR using two measurement tools: the assessment of multiple systematic reviews (AMSTAR) and level of research design scoring. Thirty‐eight SRs met inclusion criteria and 30 were analysed: 23 qualitative SRs and seven meta‐analyses. Ten SRs were related to occlusal appliances, occlusal adjustment or bruxism; eight to physical therapy; seven to pharmacologic treatment; four to TMJ and maxillofacial surgery; and six to behavioural therapy and multimodal treatment. The median AMSTAR score was 6 (range 2–11). Eighteen of the SRs were based on randomised clinical trials (RCTs), three were based on case–control studies, and nine were a mix of RCTs and case series. Most SRs had pain and clinical measures as primary outcome variables, while few SRs reported psychological status, daily activities, or quality of life. There is some evidence that the following can be effective in alleviating TMD pain: occlusal appliances, acupuncture, behavioural therapy, jaw exercises, postural training, and some pharmacological treatments. Evidence for the effect of electrophysical modalities and surgery is insufficient, and occlusal adjustment seems to have no effect. One limitation of most of the reviewed SRs was that the considerable variation in methodology between the primary studies made definitive conclusions impossible.     

多系统评价评估问卷量表在口腔医学领域中文系统评价应用中的信度和效度评价

目的 评价多系统评价评估问卷（AMSTAR）量表应用于口腔医学领域中文系统评价中的一致性、信度和效度。方法 计算机检索中国生物医学文献数据库、维普中文科技期刊数据库和中国期刊全文数据库,截止日期为 2011年3月1日。手工检索19种中文口腔医学杂志,检索已发表的口腔医学类系统评价。2名评价者分别用总体质量 评估问卷（OQAQ）量表和AMSTAR量表对系统评价进行评价,计算观察者间使用AMSTAR量表的Kappa值,AMSTAR 量表重测信度的级内相关系数（ICC）以及AMSTAR和OQAQ量表得分的最大得分百分比的级内相关系数（结构效度）。 结果 纳入52篇系统评价文献。评价者使用AMSTAR量表的Kappa值为0.81[95%C（I 0.73,0.89）],使用OQAQ量表的 Kappa 值为0.74 [95% CI（0.66,0.83）] 。 重测信度的ICC 为 0.98 [95% CI（0.97,0.99）,P =0.000]。 内部一致性信度Cronbach’α为0.69[95%CI（0.56,0.80）,P=0.000]。AMSTAR和OQAQ量表最大得分百分比的ICC为0.94[95%CI（0.90, 0.97）,P=0.000]。结论 AMSTAR量表在应用于口腔医学领域系统评价时有很好的一致性、信度和效度。AMSTAR 量表可很好的推广至口腔医学领域进行系统评价的方法学质量评价,为医务工作者进行系统评价方法学质量评价时带来了较大的便利。     

An overview of systematic reviews on the effectiveness of periodontal treatment to improve glycaemic control

Several systematic reviews with meta‐analyses on the effectiveness of periodontal treatment to improve glycaemic control have been published. So far no overview of these systematic reviews has been performed. The main objective of this report was to assess critically these systematic reviews to provide the reader with a high‐level synthesis of research evidence. MEDLINE (via PubMed) and EMBASE databases were searched independently and in duplicate to identify systematic reviews with meta‐analyses of clinical studies that assessed the relationship between diabetes mellitus and periodontitis. The last database search was performed on 10 March 2015. The reference lists of included systematic reviews were also scrutinized for further publications. The methodological quality of the included systematic reviews was assessed independently with two validated checklists (AMSTAR and OQAQ) by two authors. Disagreements in the assessment were resolved by consensus. A total of 226 potential publications were initially retrieved. Eleven systematic reviews with meta‐analyses were finally included. Glycosylated haemoglobin A1c (HbA1c) was the most commonly used clinical endpoint. Meta‐analytic estimates from systematic reviews generated an average reduction of 0.46% (median 0.40%) of HbA1c in patients with diabetes mellitus who received periodontal treatment. These meta‐analyses had, nevertheless, methodological limitations such as inclusion of trials with different types of risk of bias that hinder more robust conclusions. A recent meta‐analysis that included recently published large randomized controlled trials did not show significant change in the level of HbA1c at the 6 mo follow‐up. The AMSTAR checklist generated results that were more conservative than OQAQ. Findings from this overview do not support the information that periodontal treatment may improve glycaemic control. Methodological issues described in this overview may guide further research on this topic.     

Methodological Quality Assessment of Meta-analyses and Systematic Reviews of the Relationship Between Periodontal and Systemic Diseases

ObjectivesThe aims of this article are to identify all the published systematic reviews (SRs) and meta-analyses (MAs) that studied the relationship between periodontal and systemic diseases and to assess their quality using 2 scales (the Overview Quality Assessment Questionnaire [OQAQ] and A Measurement Tool to Assess Systematic Reviews [AMSTAR] checklist).MethodsFor SRs and MAs to be included, they should have investigated one of the following systemic diseases: pulmonary conditions, cardiac conditions, endocrine conditions, cancer, blood disorders, psychological conditions, anxiety, depression, mood disorders, and several other diseases. Two investigators screened MEDLINE via PubMed, Embase, Scopus, Web of Science, and the Cochrane Database of Systematic Reviews. The tools used to evaluate quality were the AMSTAR scale and OQAQ. The protocol was prospectively registered in PROSPERO (CRD42018102208).ResultsThe search strategy found 691 unique articles, 42 of which met the eligibility criteria and were included in this review. Diabetes mellitus was the most investigated disease (14 out of 42 studies), followed by obesity (11 studies) and cardiovascular diseases (5 studies). A total of 40 reviews reported on the characteristics of included studies, and, as per the AMSTAR scale, 39 reviews had an a priori design. The number of reviews that fulfilled the status of publication criterion was the lowest (7 reviews only), followed by the number used in the assessment of publication bias (11 reviews). The number of high-quality reviews was higher with the OQAQ than with the AMSTAR checklist (33 vs 25 studies), but the AMSTAR showed a higher number of medium-quality reviews than the OQAQ (14 vs 6 studies). Both showed the same number of low-quality reviews.ConclusionsHigh-quality SRs and MAs are crucial to understanding the relationship between systemic and periodontal diseases. Medical practitioners must be able to inform patients about oral health and specific periodontal health concerns.     

Are Short Dental Implants (<10 mm) Effective? A Meta‐Analysis on Prospective Clinical Trials

Background: This study aims to compare the survival rate of short (<10 mm) and standard (≥10 mm) rough‐surface dental implants under functional loading. Methods: An electronic literature search using PubMed and Medline databases was conducted. Prospective clinical human trials, published in English from January 1997 to July 2011, that examined dental implants of <10 mm with a 12‐month follow‐up were included in this meta‐analysis. The following data were retrieved from the included articles: the number of implants, implant dimensions, implant locations, types of prostheses, follow‐up periods, and implant survival rates. Kaplan‐Meier survival estimates and the hazard rates were analyzed and compared between short and standard implants. Results: Thirteen studies were selected, examining 1,955 dental implants, of which 914 were short implants. Short dental implants had an estimated survival rate of 88.1% at 168 months, when standard dental implants had a similar estimated survival rate of 86.7% (P = 0.254). The peak failure rate of short dental implants was found to occur between 4 and 6 years of function. This occurred at an earlier time point compared with standard dental implants, where the peak failure rate occurred between 6 and 8 years of function. Conclusions: This study shows that in the long term, implants of <10 mm are as predictable as longer implants. However, they fail at an earlier stage compared with standard implants.     

Do Implant Length and Width Matter for Short Dental Implants (<10 mm)? A Meta‐Analysis of Prospective Studies

Background: This meta‐analysis of prospective clinical trials was conducted to determine the effects of dental implant length and width on implant survival rate of short (<10 mm) implants. Methods: An electronic search of the PubMed database for relevant studies published in English from November 1998 to March 2012 was performed. Selected studies were randomized clinical trials, human clinical trials, or prospective trials with a clear aim of investigating the success or survival rate of short (<10 mm) implants. Results: Eight studies fulfilled the inclusion criteria and were subsequently analyzed. A total of 525 short (<10 mm) dental implants were analyzed, of which 253 were 3.5 mm in diameter (48.19%), 151 were 4.0 mm (28.76%), 90 were 4.1 mm (17.14%), 21 were 4.8 mm (4%), and 10 were 5.1 mm (1.9%). All implants included in this meta‐analysis had a follow‐up period of 12 to 72 months. The included studies reported on the survival rate and diameter of the implants. Six of the studies used “short implants” (7 to 9 mm), and the remaining were classified as “extra‐short implants” (≤6 mm). Five‐year estimated failure rates were 1.61% and 2.92%, respectively, for extra‐short and short implants (z = ?3.49, P <0.001, 95% confidence interval = 0.51% to 4.10%). Furthermore, it was found that the wider the implant, the higher the failure rate (estimated failure rate = 2.36%, 95% confidence interval = 1.07% to 5.23%). Conclusions: Neither implant length nor width seemed to significantly affect the survival rate of short implants (<10 mm). Nonetheless, further well‐designed randomized clinical trials are needed to confirm these findings.     

Quality assessment of systematic reviews on vertical bone regeneration

The aim of this study was to evaluate and compare the quality of systematic reviews of vertical bone regeneration techniques, using two quality-assessment tools (AMSTAR and ROBIS). An electronic literature search was conducted to identify systematic reviews or meta-analyses that would evaluate at least one of the following outcomes: implant survival, success rates, complications or bone gain after vertical ridge augmentation. Methodological quality assessment was performed by two independent evaluators. Results were compared between reviewers, and reliability measures were calculated using the Holsti’s method^® and Cohen’s kappa. Seventeen systematic reviews were included, of which seven presented meta-analysis. Mean ±95% confidence interval AMSTAR score was 6.35 [4.74;7.97], with higher scores being correlated with a smaller risk of bias (Pearson’s correlation coefficient = ?0.84; P < 0.01). Cohen’s inter-examiner kappa showed substantial agreement for both checklists. From the available evidence, we ascertained that, regardless of the technique used, it is possible to obtain vertical bone gains. Implant success in regenerated areas was similar to implants placed in pristine bone with results equating between 61.5% and 100% with guided bone regeneration being considered the most predictable technique regarding bone stability, while distraction osteogenesis achieved the biggest bone gains with the highest risk of possible complications.     

Methodological quality assessment of paper-based systematic reviews published in oral health

Objectives

This study aimed to conduct a methodological assessment of paper-based systematic reviews (SR) published in oral health using a validated checklist. A secondary objective was to explore temporal trends on methodological quality.

Material and methods

Two electronic databases (OVID Medline and OVID EMBASE) were searched for paper-based SR of interventions published in oral health from inception to October 2014. Manual searches of the reference lists of paper-based SR were also conducted. Methodological quality of included paper-based SR was assessed using an 11-item questionnaire, Assessment of Multiple Systematic Reviews (AMSTAR) checklist. Methodological quality was summarized using the median and inter-quartile range (IQR) of the AMSTAR score over different categories and time periods.

Results

A total of 643 paper-based SR were included. The overall median AMSTAR score was 4 (IQR 2–6). The highest median score (5) was found in the pain dentistry and periodontology fields, while the lowest median score (3) was found in implant dentistry, restorative dentistry, oral medicine, and prosthodontics. The number of paper-based SR per year and the median AMSTAR score increased over time (median score in 1990s was 2 (IQR 2–3), 2000s was 4 (IQR 2–5), and 2010 onwards was 5 (IQR 3–6)).

Conclusion

Although the methodological quality of paper-based SR published in oral health has improved in the last few years, there is still scope for improving quality in most evaluated dental specialties.

Clinical relevance

Large-scale assessment of methodological quality of dental SR highlights areas of methodological strengths and weaknesses that can be targeted in future publications to encourage better quality review methodology.

     

Methodological Quality Assessment of Meta-analyses in Endodontics

Introduction

The objectives of this review were to assess the methodological quality of published meta-analyses related to endodontics using the assessment of multiple systematic reviews (AMSTAR) tool and to provide a follow-up to previously published reviews.

Extent and quality of systematic review evidence related to minimum intervention in dentistry: essential oils, powered toothbrushes, triclosan, xylitol

Objective: To investigate extent and quality of current systematic review evidence regarding: powered toothbrushes, triclosan toothpaste, essential oil mouthwashes, xylitol chewing gum. Methods: Five databases were searched for systematic reviews until 13 November 2010. Inclusion criteria: relevant to topic, systematic review according to title and/or abstract, published in English. Article exclusion criteria were based on QUOROM recommendations for the reporting of systematic review methods. Systematic review quality was judged using the AMSTAR tool. All trials included by reviews were assessed for selection bias. Results: 119 articles were found, of which 11 systematic reviews were included. Of these, six were excluded and five accepted: one for triclosan toothpaste; one for xylitol chewing gum; two for powered toothbrushes; one for essential oil mouthwashes. AMSTAR scores: triclosan toothpaste 7; powered toothbrushes 9 and 11; xylitol chewing gum 9; essential oil mouthwashes 8. In total, 75 (out of 76) reviewed trials were identified. In‐depth assessment showed a high risk of selection bias for all trials. Conclusions: The extent of available systematic review evidence is low. Although the few identified systematic reviews could be rated as of medium and high quality, the validity of their conclusions needs to be treated with caution, owing to high risk of selection bias in the reviewed trials. High quality randomised control trials are needed in order to provide convincing evidence regarding true clinical efficacy.     

Patient-related risk factors for implant therapy. A critique of pertinent literature

Background: Treatment planning for dental implants involves the assessment of patient‐related risk factors prior to formulation of a treatment plan. The aim of this review was to assess relevant literature and provide evidence‐based information on the successful surgical placement of dental implants. Methods: An electronic search of Medline, PubMed and the Cochrane Databases of Systematic Reviews was undertaken using a combination of MeSH terms and keywords. A handsearch was also performed and cross‐referenced with articles cited in papers selected. The primary study parameter was implant failure. Results: Forty‐three studies were selected based on specific inclusion criteria. Many studies contain confounding variables, numbers in subcategories are often too small for meaningful statistical analysis, and follow‐up times vary and are often short‐term. Conclusions: There are many risk factors which the clinician is required to know and understand to advise patients, and consider in planning and treatment provision. Consistent evidence exists to show an increased failure rate with smokers, a history of radiotherapy and local bone quality and quantity. Weaker evidence exists to show a higher incidence of peri‐implant disease in patients with a history of periodontitis‐related tooth loss. Lack of evidence precludes definitive guidelines for patients with autoimmune disorders where expert opinion recommends caution. Osteoporotic patients show acceptable survival rates; however patients on oral bisphosphonates show a small incidence but high morbidity from osteonecrosis of the jaw. Emerging evidence suggests that there is a correlation between genetic traits and disruption of osseointegration.     

Dental and skeletal effects of palatal expansion techniques: a systematic review of the current evidence from systematic reviews and meta‐analyses

The aim was to assess the quality and to summarise the findings of the Systematic Reviews (SRs) and Meta‐Analyses (MAs) on the dental and skeletal effects of maxillary expansion. Electronic and manual searches have been independently conducted by two investigators, up to February 2015. SRs and MAs on the dentoalveolar and skeletal effects of fixed expanders were included. The methodological quality was assessed using the AMSTAR (A Measurement Tool to Assess Systematic Reviews). The design of the primary studies included in each SR/MA was assessed with the LRD (Level of Research Design scoring). The evidence for each outcome was rated applying a pre‐determined scale. Twelve SRs/MAs were included. The AMSTAR scores ranged from 4 to 10. Two SRs/MAs included only RCTs. The current findings from SRs/MAs support with high evidence a significant increase in the short‐term of maxillary dentoalveolar transversal dimensions after Rapid Maxillary Expansion (RME). The same effect is reported with moderate evidence after Slow Maxillary Expansion (SME). However, there is moderate evidence of a non‐significant difference between the two expansion modalities concerning the short‐term dentoalveolar effects. With both RME and SME, significant increase of skeletal transversal dimension in the short‐term is reported, and the skeletal expansion is always smaller than the dentoalveolar. Even though dental relapse to some extent is present, long‐term results of the dentoalveolar effects show an increase of the transversal dimension, supported by moderate evidence for RME and low evidence for SME. Skeletal long‐term effects are reported only with RME, supported by very low evidence.     

Antibiotic prophylaxis in oral and maxillofacial surgery: a systematic review

Surgical site infections are a complication of oral and maxillofacial procedures, with the potential for significant morbidity and mortality. Use of preoperative, perioperative, and postoperative antibiotic prophylaxis to reduce the incidence of surgical site infections must be balanced with considerations of a patients’ risk of antibiotic-related adverse events. This review aimed to provide evidence-based recommendations for antibiotic prophylaxis. Searches were conducted using MEDLINE, the Cochrane Library, EMBASE, and PUBMED for maxillofacial procedures including: treatment of dental abscesses, extractions, implants, trauma, temporomandibular joints, orthognathics, malignant and benign tumour removal, and bone grafting, limited to articles published since 2000. A total of 98 out of 280 retrieved papers were included in the final analysis. Systematic reviews were assessed using AMSTAR criteria. Randomised controlled trials were assessed for bias using Cochrane Collaborative tools. The overall quality of evidence was assessed using GRADE. Prophylactic antibiotic use is recommended in surgical extractions of third molars, comminuted mandibular fractures, temporomandibular joint replacements, clean-contaminated tumour removal, and complex implants. Prophylactic antibiotic use is not routinely recommended in fractures of the upper or midface facial thirds. Further research is required to provide recommendations in orthognathic, cleft lip, palate, temporomandibular joint surgery, and maxillofacial surgical procedures in medically-compromised patients.     

An AMSTAR assessment of the methodological quality of systematic reviews of oral healthcare interventions published in the Journal of Applied Oral Science (JAOS)

Background

Systematic reviews are not an assembly of anecdotes but a distillation of current best available evidence on a particular topic and as such have an important role to play in evidence-based healthcare. A substantial proportion of these systematic reviews focus on interventions, and are able to provide clinicians with the opportunity to understand and translate the best available evidence on the effects of these healthcare interventions into clinical practice. The importance of systematic reviews in summarising and identifying the gaps in evidence which might inform new research initiatives is also widely acknowledged. Their potential impact on practice and research makes their methodological quality especially important as it may directly influence their utility for clinicians, patients and policy makers. The objectives of this study were to identify systematic reviews of oral healthcare interventions published in the Journal of Applied Oral Science (JAOS) and to evaluate their methodological quality using the evaluation tool, AMSTAR.

Methods

Potentially eligible systematic reviews in JAOS were identified through an electronic search of the Scientific Electronic Library Online (SciELO). Details of the relevant aspects of methodology as reported in these systematic reviews were extracted from the full text publications. Methodological quality was assessed independently by two reviewers using the AMSTAR questionnaire.

Results

Five systematic reviews were identified, one of which was subsequently excluded as it was a review of a diagnostic test. Summary AMSTAR scores for the four included reviews were: 1, 5, 2 and 4 out of a maximum score of 11 (range 1-5, mean 3) with only one of the reviews scoring 5.

Conclusion

AMSTAR evaluation of the methodological quality of the relatively small number of systematic reviews published in JAOS illustrated that there was room for improvement. Pre-publication and editorial appraisal of future systematic reviews might benefit from the application of tools such as AMSTAR and is to be recommended.