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Reviews of evidence on interventions to prevent dental caries, oral and pharyngeal cancers, and sports-related craniofacial injuries |
Truman B I, Gooch B F, Sulemana I, Gift H C, Horowitz A M, Evans C A, Griffin S O, Carande-Kulis V G |
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Authors' objectives To review the effectiveness, applicability, other effects, economic evaluations and barriers to the use of selected population-based interventions intended to prevent or control dental caries, oral and pharyngeal cancers and sports-related craniofacial injuries.
Searching MEDLINE was searched from 1966 to 2000. The search terms were not given. The reference lists of the retrieved articles were also examined, and experts who were not members of the review development team were contacted. Only articles written in the English language were included.
Study selection Study designs of evaluations included in the reviewAny study that compared a group of people who had been exposed to the intervention with a group of people who had not been exposed, or who had been less exposed, was eligible for inclusion in the review. The comparisons could be concurrent or in the same group over a period of time. The included study designs were: cross-sectional survey; no- randomised trial; prospective cohort; time series; before-and-after; retrospective cohort; randomised trial; and diagnostic test accuracy studies.
Specific interventions included in the reviewEvidence reviews were carried out on five interventions organised into three groups on the basis of oral disease outcome of interest: (1) interventions to prevent or control dental caries; (2) interventions to prevent or control oral and pharyngeal cancers; and (3) interventions to prevent or control sport-related craniofacial injuries. The five interventions were: community water fluoridation (CWF); school-based sealant delivery programmes; community-wide sealant promotion programmes; cancer awareness and screening programmes; and promoting the use of dental and craniofacial protectors in contact sports.
Participants included in the reviewThe effects on communities, rather than on people, were evaluated. The included studies involved communities such as worksites, schools, religious faiths, and health facilities or social services. State, county, district and country-wide programmes were also included. The paper provided descriptions of all the included communities.
Outcomes assessed in the reviewThe outcomes of interest in the CWF and school-based or school-linked pit and fissure sealant delivery programme reviews were: decayed, missing or filled primary or permanent teeth; decayed, extracted or filled primary or permanent teeth; decayed, missing or filled surfaces in primary or permanent teeth; and the percentage of caries-free children.
The outcome of interest in the statewide or community-wide sealant promotion programmes review was sealant use, as reported by dentists.
The outcomes of interest in the review of population-based interventions for early detection of oral and pharyngeal pre-cancers and cancers were: the accuracy of early detection, i.e. sensitivity, specificity, positive predictive value and negative predictive value; and the effectiveness of early detection, i.e. the percentage yield of suspicious lesions, pre-cancers or cancers, and cancer morbidity and mortality.
The outcomes of interest in the review of population-based interventions to encourage the use of helmets, facemasks and mouthguards in contact sports, were the injury rate (head, neck, face, mouth and teeth) and the use of helmets, facemasks and mouthguards.
How were decisions on the relevance of primary studies made?The authors do not state how the papers were selected for the review, or how many of the reviewers performed the selection.
Assessment of study quality Judgements about the suitability of the study design for estimating the effectiveness of the intervention were made. The study designs of greatest suitability had concurrent comparison groups and prospective measurement of exposure and outcome; the study designs of moderate suitability included all retrospective designs or multiple before-and-after measurements, but no concurrent comparison group; and the study designs of least suitability involved single before-and-after measurements and no concurrent comparison group or exposure, with outcome measures in a single group at the same point in time. Residual threats to the validity of the conclusions, arising from the quality of study execution, were assessed according to Community Guide methods (see Other Publications of Related Interest nos.1-2). The quality of execution of each study was characterised as good, fair or limited on the basis of the total number of categories with limitations. Good studies had one or no assessed limitations, fair studies had two to four, while limited studies had at least five. Studies with limited execution were excluded from the analysis. Judgements of validity were made by two reviewers using a standardised form. Any disagreements between the reviewers were reconciled by consensus among the coordination team members. The evaluated studies were presented and discussed in meetings of the coordination team.
Data extraction The data were extracted by two reviewers using a standardised form. Any disagreements between the reviewers were reconciled by consensus among the coordination team members. The evaluated studies were presented and discussed in meetings of the coordination team.
Data were extracted on the study period, design, setting, interventions and comparison, study population description, sample size, outcomes, results and follow-up time. The results of each study (change in oral health) were presented as point estimates, and as a percentage of the best available baseline measure using different formulae for different health outcomes and study designs. These formulae were presented in the review.
Methods of synthesis How were the studies combined?The results of individual studies on a particular intervention were displayed in tabular format and as figures, and the median and range of the effect measures were reported. The strength of the body of evidence was summarised on the basis of the numbers of available studies, the strength of their design and execution, and the size and consistency of the reported effects (see Other Publications of Related Interest no.1).
How were differences between studies investigated?There was no formal investigation of heterogeneity.
Results of the review Twenty-one studies were included in the CWF review: 8 cross-sectional surveys, 1 non-randomised trial, 8 prospective cohort studies and 4 time series studies. Ten studies were included in the school sealant review: one before-and-after study, 4 non-randomised trials, one retrospective cohort study, 3 randomised trials and one time series study. One study (before-and-after) was included in the state- and community-wide sealant review. Seven studies were included in the cancer screening review: one randomised trial, 2 prospective cohort studies, one time series study, one cross-sectional survey, one retrospective cohort study and one non-comparative demonstration. Four studies of unspecified design were included in the sports-related injuries review.
CWF.
The included studies varied by design, analysis models, levels of analysis, measures of dental caries occurrence, differences in the fluoride concentrations being compared, and the direction of change in exposure to CWF over time. The studies were grouped into three subsets: group A, before-and-after measurements of caries at the tooth level in studies with concurrent comparison groups; group B, post-exposure measurements of caries at the tooth level in studies with concurrent comparison groups; and group C, measured effects of CWF on caries at any level (tooth surface or child) using any study design. Seven group A studies showed that starting or continuing water fluoridation decreased dental caries experience among children aged 4 to 17 years by a median of 29.1% during 3 to 12 years of follow-up. Two studies showed negative effects of continuing water fluoridation. The authors noted that these inconsistencies appear to have resulted from inadequate control of confounding.
Three group A studies found that stopping fluoridation was associated with a median 17.9% increase in dental caries during 6 to 10 years of follow-up.
Seven group B studies found that starting water fluoridation decreased dental caries experience among children aged 4 to 17 years by a median of 50.7% during 3 to 12 years of follow-up.
The authors stated that the group C studies were too heterogeneous to summarise. However, overall, this subset of effect measures did not alter the main findings of the analyses in groups A and B.
The authors stated that the results of the review should apply to most populations in the United States and other industrialised countries. Major barriers to the adoption or maintenance of CWF include limited knowledge among the general population and some health professionals of oral health promotion, some organised opposition to CWF, and some continuing debate about the net balance of benefits and risk of harm from excess fluoride ingested from all sources.
School-based or school-linked pit and fissure sealant delivery programmes.
Seven of the 10 studies reported on the effects of using the sealant bisphenol-A-glycidyl methacrylate (bis-GMA) resin as the only caries preventive intervention, while 3 reported on the effects of using bis-GMA sealant combined with other caries preventive interventions (fluoride gel or rinse, health education or fluoridated water). Exposure to the intervention was associated with a median relative decrease in dental caries experience of 60% (range: 5 to 93). The effects were similar for studies in the USA (median 60%, range: 23 to 78) and those outside of the USA (median 60%, range: 5 to 93). School-based programmes showed a higher median effect (median 65%, range: 23 to 93) than school-linked programmes (37%, range: 5 to 93). Programmes in which sealants were reapplied at some point showed a higher median effect (65%, range: 23 to 93) than those in which the sealants were not reapplied (30%, range: 5 to 93).
The authors stated that the findings should apply broadly to populations of school-aged children in a range of school settings. Major barriers to the adoption or maintenance of school-based or school-linked sealant delivery programmes include: limited knowledge of oral health promotion among the general population and some health professionals; limited resources and limited political and administrative support in some school districts; state dental practice laws and regulations that limit the authority to apply sealants to selected categories of dental care professionals; and resistance of the private practice dental community.
Statewide or community-wide sealant promotion programmes.
The one study that met the inclusion criteria provided insufficient evidence to support a recommendation, because the change in sealant use or caries experience attributable to the intervention could not be estimated from the data presented.
Prevention or control of oral and pharyngeal cancers.
Estimates of the accuracy of screening activities varied widely (sensitivity 59 to 97%, specificity 69 to 99% and positive predictive value 31 to 87%) within ranges reported in other published reviews. No studies reported estimates of effect in terms of morbidity, mortality or quality of life.
Prevention or control of sports-related craniofacial injuries.
The four studies that met the inclusion criteria provided insufficient evidence to meet the minimum requirements for a Task Force recommendation.
Cost information CWF: seven studies indicated that the median cost of the CWF programme per person per year ranged from $2.70 among 19 systems serving 5,000 people or less, to $0.40 among 35 systems serving 20,000 people or more. Five studies that included sufficient data to calculate a cost-effectiveness ratio indicated that CWF was cost-saving in all studies. The authors also estimated the annual decay incidence required for fluoridation to be cost-saving for smaller communities (5,000 to 20,000 residents).
School-based or school-linked sealant programmes: six studies were found. The sealant programme costs per person served ranged from $18.50 to $59.83 (median $39.10). Four studies included sufficient data to calculate the cost-effectiveness ratios, which ranged from cost-saving (less than $0) to $487. The authors calculated that a programme that sealed permanent first molars would be cost-saving if unsealed molars were decaying at the average rate of more than 0.47 surfaces per year.
Statewide or community-wide sealant programmes: evidence on the cost-effectiveness was not sought because the effectiveness of the intervention was not established.
Early detection of pre-cancers and cancers: evidence on the cost-effectiveness was not sought because the effectiveness of the intervention was not established.
Prevention or control of sports-related craniofacial injuries: evidence on the cost-effectiveness was not sought because the effectiveness of the intervention was not established.
Authors' conclusions There was strong evidence that CWF is effective in reducing the cumulative experience of dental caries within communities.
There was strong evidence that school-based and school-linked sealant delivery programmes are effective in reducing decay in pits and fissures of children's teeth.
There was insufficient evidence to determine the effectiveness of statewide or community-wide sealant promotion programmes to prevent dental caries.
There was insufficient evidence to determine the effectiveness of population-based interventions for the early detection of pre-cancers and cancers in improving morbidity, mortality or quality of life.
There was insufficient evidence to determine the effectiveness of population-based interventions to encourage the use of helmets, facemasks and mouthguards in contact sports, in increasing equipment use or reducing injury-related morbidity or mortality.
CRD commentary This was a collection of related systematic reviews that had clear and explicit review questions and inclusion criteria. Details of the review process were mostly reported, and a validity assessment was undertaken and the results reported. Details of the studies were given in the appendices. The authors stated that some studies were excluded on the grounds of limited validity; however, these studies appear to have been included in the main text of the review, although no conclusions are drawn from them. The literature search was limited to MEDLINE, which is probably insufficient for reviews of population-based interventions. It is therefore possible that some relevant studies have been missed.
The authors' conclusions are suitably cautious, given the limited validity of some of the included studies, but it should be noted that more evidence probably exists than was included in this review.
Implications of the review for practice and research Practice: The authors did not make explicit recommendations for practice other than those contained within their conclusions.
Research: The authors state that the following questions remain unanswered.
The research questions in relation to community water fluoridation (CWF) are:
What is the effectiveness of laws, policies and incentives to encourage communities to start or continue water fluoridation? What is the effectiveness of CWF in reducing socio-economic or racial and ethnic disparities in caries burden? What is the effectiveness of CWF among adults (aged 18 years or more)? What are the effects of the increasing use of bottled water and in-home water filtration systems? How effective is CWF in preventing root-surface caries?
The research questions in relation to school-based or school-linked pit and fissure sealant delivery programmes are:
What is the effect of sealant delivery programmes among adults aged at least 18 years? How do state dental practice laws and regulations affect the use of sealants in school-based programmes? How do school district oral health policies and curricula affect the use of sealants? What is the effectiveness of sealants in primary teeth?
The research questions in relation to statewide or community-wide sealant promotion programmes are:
What is the effect of public education on awareness, community mobilisation (through coalitions) and resource allocation for sealant production? What is the effect of professional education, combined with provider reminders and other system-oriented strategies, on knowledge, skills and appropriate use of sealants? How cost-effective are models of sealant delivery other than school-based?
The research questions in relation to preventing and controlling oral and pharyngeal cancers are:
How sensitive and specific is oral examination as a screening tool? How valid and reliable is oral examination conducted by various dental and medical practitioners in detecting pre-cancerous and cancerous lesions? How sensitive and specific is oral examination aided by endoscopy, brush biopsy, vital staining, genetic markers and other emerging clinical technologies? Is the use of oral self-examination kits feasible, valid and reliable? How effective are individual or population-based interventions in detecting pre-cancers and reducing the incidence of invasive cancer? Are population-based interventions effective in detecting pre-cancers and early cancers, and is early detection of pre-cancers and cancers effective in reducing cancer morbidity and mortality or improving quality of life? How effective are population-based interventions in reducing disparities in oral cancer incidence and mortality? What is the effect on oral cancer incidence, stage distribution and mortality of reducing alcohol and tobacco exposure? What effects do education interventions and materials have on awareness of oral cancer and the prevention behaviour of consumer groups, health care providers, health care organisations and government agencies? What are the effects of early detection on morbidity, mortality and quality of life among population subgroups at high risk for oral cancer?
How effective are laws, policies and incentives in encouraging health care providers to conduct oral examinations for cancer detection in high-risk populations?
The research questions in relation to preventing and controlling sports-related craniofacial injuries are:
How effective are laws, policies and incentives in increasing the use of protective equipment in various sports? How effective are organised programmes in increasing the use of protective equipment? What is the effect on injury risk of increasing use of protective equipment in particular sports? What are the extent and causes of disparities in equipment use and injury risk by age, gender, race or ethnicity, type of sport and other factors? How effective are various kinds of helmets, mouthguards and facemasks in preventing oral-facial injuries in contact sports?
Bibliographic details Truman B I, Gooch B F, Sulemana I, Gift H C, Horowitz A M, Evans C A, Griffin S O, Carande-Kulis V G. Reviews of evidence on interventions to prevent dental caries, oral and pharyngeal cancers, and sports-related craniofacial injuries. American Journal of Preventive Medicine 2002; 23(1 Supplement): 21-54 Other publications of related interest 1. Briss PA, Zaza S, Pappaioanou et al, and the Task Force on Community Preventive Services. Developing an evidence-based Guide to Community Preventive Services - methods. Am J Prev Med 2000;18 Suppl 1:35-43. 2. Zaza S, Wright-De Aguero LK, Briss PA, et al, and the Task Force on Community Preventive Services. Data collection instrument and procedure for systematic reviews in the Guide to Community Preventive Services. Am J Prev Med 2000;18 Suppl 1:44-74.
Indexing Status Subject indexing assigned by NLM MeSH Athletic Injuries /prevention & Dental Caries /prevention & Dental Health Services; Evidence-Based Medicine; Facial Injuries /prevention & Fluoridation; Health Promotion; Humans; Mouth Neoplasms /prevention & Oral Health; Pharyngeal Neoplasms /prevention & Preventive Dentistry; Preventive Health Services; Skull /injuries; United States; control; control; control; control; control AccessionNumber 12002001726 Date bibliographic record published 30/04/2003 Date abstract record published 30/04/2003 Record Status This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn. |
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