Welcome - Aims and objectives of the Symposium - Bill Shaw (Co-ordinating Editor, Cochrane Oral Health Group, UK)

Cochrane Oral Health Group 10 years on & what is a Cochrane systematic review - Helen Worthington (Co-ordinating Editor, Cochrane Oral Health Group, UK)

The Cochrane OHG's UK base was established in August 1996. With an editorial team consisting of 10 Editors and 3 support staff, the group has grown considerably over the last 10 years. Achievements include a worldwide network of 624 members from 40 countries; an OHG Trials Register containing over 20,000 entries; 54 reviews and 68 protocols published on The Cochrane Library (Issue 3, 2006); and recently receiving NIDCR funding to undertake a series of oral cancer reviews. The editorial process for undertaking a systematic review with the OHG was discussed.

Cochrane: a view from the chair - Stephen Hancocks (Editor-in-Chief, British Dental Journal, UK)

Dental decision making needs to be informed by good quality evidence. Improving 2-way communication between practitioners and the research community is particularly important in situations where there is insufficient evidence from Cochrane systematic reviews to aid decision making.

Evidence based dentistry: an international perspective - James Bader (Research Professor, University of North Carolina, USA)

The OHG has achieved a great deal in the last 10 years however only 20% of its reviews answer a question without equivocation. Issues for the future include maintaining the flow of new reviews, updating 'elderly' reviews, deleting 'elderly' protocols and improving the utility of reviews for practitioners. To increase the visibility and usability of Cochrane OHG reviews it is important that they feature highly on internet search engine results and address topics that are of importance to practitioners and the public. Implementation of evidence based dentistry (EBD) at the individual practitioner level and the use of EB practice guidelines have been shown to be ineffective. Continuing professional dental education has limited effectiveness and there is unproven effectiveness for the use of peer review and clinical audit. Methods that might be effective in influencing practitioner behaviour include: EBP assessment for relicensure (EB performance measures); EB reimbursement (payment for appropriateness and effectiveness); and the use of EB psychological models for behavioural change.

How far have we come? A personal reflection on the bimodally distributed opinions on water fluoridation - Iain Chalmers (Editor, James Lind Library, UK)

There is unequivocal evidence from a series of Cochrane OHG reviews that topical fluorides reduce the incidence of caries. The effects of mass medication using water fluoridation were investigated in a systematic review by the University of York. Water fluoridation probably reduces caries by an average of 15% overall, has an effect over and above toothpaste, may reduce inequalities between social groups, probably causes more mottled teeth than previously thought and may or may not cause other harms such as cancer, bone problems etc. These findings are however based on poor quality evidence and more research is needed. This call for further research was supported by an MRC Working Group Report in 2002. There have been several examples of misrepresentation of the research evidence from the systematic review. Iain Chalmers has written to Melanie Johnston (Minister for Public Health) to suggest commissioning the Cochrane OHG to update the York review and publish it in The Cochrane Library; funding people with no vested interest to develop methods to familiarise local communities with the research evidence; and develop and apply methods to help local communities make informed choices among alternative policies.

What is going on in the specialties: introduction - Bill Shaw (Co-ordinating Editor, Cochrane Oral Health Group, UK) &
Jan Clarkson (Dental Health Services Research Unit, University of Dundee, UK)

For each of the specialties, the following format was suggested: (1) Introduction on current clinical practice within the specialty area; (2) Cochrane reviews and other important systematic reviews; (3) Overview of the amount of trials published, the topics they cover and is there a large body of trials that needs assessing and incorporating into systematic reviews? (4) Gaps, uncertainties, future research.

What is going on in the specialties: caries prevention - Valeria Marinho (Queen Mary's School of Medicine & Dentistry, UK)

Dental caries, although declining, is still the most prevalent dental disease and there are considerable variations in the use of various approaches to prevent and treat caries.
Cochrane systematic review topics: topical fluorides (7 reviews, 1 protocol), fluorides in orthodontic treatment, fluoridated milk, pit and fissure sealants (1 review, 1 protocol), slow-release fluoride devices, xylitol and ozone therapy.
Systematic reviews (DARE/HTA databases) - 20 relevant reviews.
Trials - majority in fluorides (750+), sealants (170+) and chlorhexidine (100+).
Future research - adverse effects of topical fluoride therapies, F varnishes, fissure/glass ionomer sealants, water fluoridation and fluoridated milk.

What is going on in the specialties: periodontology - Richard Tucker (UCL Eastman Dental Institute, UK)

Cochrane systematic review topics: guided tissue regeneration, enamel matrix derivatives, routine scale and polish and manual versus powered toothbrushes.
Cochrane has contributed to the increase in EB periodontology, providing training at the European Workshop in Periodontology 2002 and World Workshop in Periodontology 2003. The Journal of Clinical Periodontology has agreed to adopt CONSORT to improve reporting of RCTs.

What is going on in the specialties: implants/prosthetics - Marco Esposito (School of Dentistry, The University of Manchester, UK)

Cochrane systematic review topics: osseointegrated dental implants (11 reviews) including bone augmentation procedures, implant types, loading methods, maintenance, surgical techniques, timing to insert implants, perimplantitis, preprosthetic surgery versus implants, antibiotics, zygomatic implants and hyperbaric oxygen therapy. Prosthetics (1 review) on denture chewing surface designs.

What is going on in the specialties: orthodontics - Jayne Harrison (Liverpool University Dental Hospital, UK)

Cochrane systematic review topics: adhesives for fixed orthodontic brackets, fluorides to prevent white spots, oral appliances for sleep apnoea, orthodontic treatment for posterior crossbites, retention procedures and feeding interventions for cleft lip, cleft palate and cleft lip and palate infants. Cochrane protocols (12).
Systematic reviews (DARE/HTA): oral appliances for snoring/sleep apnea, orthodontics and TMD, fixed slow maxillary expansion treatment and orthodontic treatment for unilateral posterior crossbite.
Trials: 883 reports in CENTRAL (May 2006), including dental bonding (132), functional (83) and extraoral traction (45).

What is going on in the specialties: oral medicine - Joanna Zakrzewska (Queen Mary's School of Medicine & Dentistry, UK)

Cochrane systematic review topics: oral lichen planus, preventing and treating oral candidiasis and mucositis in cancer patients, oral leukoplakia, burning mouth syndrome and tongue scraping. Protocols: recurrent aphthous stomatitis, denture stomatitis and salivary gland dysfunction due to radiotherapy.
Several systematic reviews were completed as part of the World Workshop in Oral Medicine and it was suggested that these be converted to Cochrane systematic reviews.

What is going on in the specialties: dental public health - Peter Robinson (School of Clinical Dentistry, University of Sheffield, UK)

Dental public health includes the commissioning of health services (which services and which configuration) and health promotion. Increasing number of reviews about clinical interventions to inform evidence based commissioning (129 Cochrane OHG reviews). Configuring services - limited evidence. Cochrane systematic review topics: dental recall, routine scale and polish, payment schemes for primary care physicians.
Health promotion: limitations to undertaking RCTs within this area. Other evaluation methods are required and groups such as the Cochrane Health Promotion and Public Health Field are exploring methods to undertake systematic reviews in this area.

What is going on in the specialties: oral surgery/pain relief - Paul Coulthard (School of Dentistry, The University of Manchester, UK)

Cochrane systematic review topics: asymptomatic impacted wisdom teeth, domestic violence screening, oral cancer screening, prevention/treatment of oral mucositis/candidiasis in cancer patients, antibiotics for bacterial endocarditis and antibiotics for irreversible pulpitits. Protocols (19).

What is going on in the specialties: restorative/endodontics - Jan Clarkson (Dental Health Services Research Unit, University of Dundee, UK) on behalf of Alison Qualtrough (School of Dentistry, The University of Manchester, UK)

Cochrane systematic review topics: ceramic inlays, veneers, ozone therapy, pit and fissure sealants, pulp treatment in primary teeth and antibiotics for irreversible pulpitis.
Systematic reviews (DARE/HTA): dental restoration longevity, acute apical absesses, filling materials, glass ionomer cements and fixed partial denture survival.
Trials from National Research Register include ion leachable glasses versus amalgam, pulp protection by bonding, adhesive bridges in primary care and endodontics in general dental practice.

Gaps in the evidence/ADA initiative - Amid Ismail (School of Dentistry, University of Michigan, USA)

The ADA has developed an evidence based dentistry (EBD) plan which includes: educating ADA members; advocating that systematic reviews be conducted before policies are developed; define clinically relevant questions for systematic review; develop an online database with systematic review summaries, clinical recommendations, and analyses; develop a business plan for an ADA Center of EBD and advocate for funding to answer clinical questions.
Only 20% of the conclusions from OHG reviews' are based on good evidence. Need to consider how to assess other levels of evidence when there is no evidence from Cochrane systematic reviews.
A survey of ADA members was carried out in 2004 to identify questions that were of importance to dentists. For several of these questions a panel of experts assessed the body of evidence, recommendations were developed and disseminated in practical user-friendly reports. Several theories to implement EBD in clinical practice were discussed.

Break out sessions:
Where are the gaps/future plans for filling these gaps/what areas need looking at?:

Suggested questions include:
Where are the gaps?
Future plans for filling these gaps?
Who is responsible for filling these gaps?
Who will fund this work?
What research/trials are needed to set the scene for this research?

Gaps: caries prevention - Valeria Marinho (Queen Mary's School of Medicine & Dentistry, UK) / Helen Worthington (Co-ordinating Editor, Cochrane Oral Health Group, UK) / Sue Pavitt (Cochrane Oral Health Group, UK)

Gaps
Good knowledge of older children and adults, need research on younger children.
Topical fluorides (need better quality research).
Sealants in primary dentition (cost effectiveness data).
Prevention of caries infection from mother to child.
Diagnostic tests for identification of caries.
Fissure sealants - primary and secondary teeth.
Health economic research e.g. management of caries in 5 year olds.
Adverse effects of fluoride interventions.
Caries prevention - management of small and more extensive lesions.
Future plans
Stratification of research by social class and risk group.
Behavioural management research.
Protocol development for fluoride interventions.
Lobbying for commissioned research of good quality and journals to adopt the CONSORT statement, express the need for this research in the public forum and report the findings of systematic reviews.
Funding
Top down
Co-ordinated large national trials of caries management.
National Institute Health Research.
Public Health Schools Programme.
Bottom up
Capacity building.
Primary care dentist involved in reviews.
Controversies
To treat or not to treat (big lesions and small initial lesions)?
Caries prevention - restorative management (SIC versus resin sealants)
Water fluoridation - how and when do we get higher quality evidence?
Dental education.

Gaps: restorative/endodontics - Paul Brunton (Leeds Dental Institute, UK), periodontology - Richard Tucker (UCL Eastman Dental Institute, UK), implants/prosthetics - Marco Esposito (School of Dentistry, The University of Manchester, UK) & Anne-Marie Glenny (School of Dentistry, The University of Manchester, UK)

Gaps
Public health (global relevance of periodontal treatment, prevalence at a population level and prevention).
Periodontitis as a risk for systemic diseases.
Host modulating treatments.
Implants in periodontitis patients (success and complications).
Identification of at risk patients at an early age.
Iatrogenic factors as a risk for periodontitis.
Predictability of treatment (factors that determine success, psychological factors).
Treatment without recession.
Routine scaling and polishing (frequency of visits with different risk groups, quality of S&P, primary versus secondary care, comparison of instrumentation and risk assessment validation).
Extraction of tooth/teeth and replacement (periodontal treatment versus extraction, endodontic treatment versus nothing/extraction, need to replace molar teeth, adhesive anterior dentistry versus implants, treatments for molar teeth).
Endodontics (retreatment, patient outcomes and quality of life).
Prosthodontics (post design, apexification and caries treatment).
Tooth whitening (harms in the long term, systemic and local factors over time and whitening versus veneers/crowns).
Patient reported outcomes (short term e.g. cost, discomfort, long term e.g. ability to sustain plaque control, quality of life, aesthetics, tooth loss and cost of tooth replacement).
Difficulties in periodontology research
Need for long term follow up (>10 years).
Healthcare costs (individual) tooth replacement or treatment.
Lobbying for RCTs when there is a large body of lesser quality evidence.
Caries management.

Gaps: orthodontics - Jayne Harrison (Liverpool University Dental Hospital, UK) & Bill Shaw (Co-ordinating Editor, Cochrane Oral Health Group, UK)

Gaps
Technical questions (bracket type, arch wire sequence, OB reduction, bands or bonds for molars).
Extraction versus non-extraction (extraction patterns).
Anchorage (HG/palatal implant/mini-implants).
Inter-visit span.
Generalist versus specialist treatment.
Is orthodontics necessary?
Future plans
Systematic review on space closure.
Increase in clinical trials with patient centred outcomes.
Look at alternatives to orthodontics e.g. borderline patients and the use of counselling/psychological counselling strategies.
Who is responsible?
Research/clinician networks and everyday providers.
Funding
Pump-priming, a survey of current practice.
Companies but there is a conflict of interest.
Orthodontic Societies' stamp of approval.
Orthodontic societies.
NHS R&D/NIH Government.

Gaps: oral medicine - Joanna Zakrzewska (Queen Mary's School of Medicine & Dentistry, UK) & Emma Tavender (Cochrane Oral Health Group, UK)

Gaps
Oral cancer screening - diagnosis and frequency.
Recurrent aphthous stomatitis (Cochrane protocol).
Denture stomatitis (Cochrane protocol).
Dry mouth/xerostomia (need pharmacology interventions for all types of xerostomia).
Oral leukoplakia - surgical interventions (will probably be cohorts).
Oral lichen planus - active controls not just placebo and long term prognosis.
Candidiasis in immunocompromised patients.
Herpes simplex.
Blistering.
Erythema multiforma.
Osteoradionecrosis and the adverse effects associated with bisphosphanates.
Trigeminal neuralgia pain.
Future plans
Contact those who completed systematic reviews at the World Workshop in Oral Medicine and ask if they would be willing to convert their reviews to Cochrane.
Closer links with the Cochrane Skin Group.
Recruit Masters students to update systematic reviews.

Gaps: oral surgery/pain relief - Paul Coulthard (School of Dentistry, The University of Manchester, UK) & David Moles (Eastman Dental Institute, UK)

Gaps
Oral cancer screening - update on way and recent HTA report.
Retreatment versus surgical endodontics; retreatment versus implants.
Orthognathic.
Pain relief.
Survey of current practice?
Future plans
Strategic thinking and mapping the gaps.
Who is responsible?
Specialists, GDP, patients, junior staff, trainees?
Who is driving the agenda? Who has ownership?
Collaborations? Need methodologists as part of the team.
Professionally commissioned reviews e.g. NICE.
Funding
Difficult, compete with medicine for money. Mortality more likely to be funded than morbidity.
Issues with industry (pragmatic versus idealistic).
Charity.
Professional reviews.
Trials?
Large trials, issues surrounding multicentre trials.
Updating reviews takes time and money.
Industry need to complete drug trials e.g. pain.
Controversies
Peer pressure in oral surgery there are strong personalities.
Issues surrounding the methodologies, health economics and ethics surrounding oral surgery research.
Within oral surgery research there is an enthusiasm for trying new fads.

Dissemination of the research evidence, progress and challenges - JA Muir Gray (Director, NHS National electronic Library for Health, UK)

A National Oral Health Knowledge Service is needed as nationally produced knowledge is not put into practice or even available consistently. Clinicians are confused by multiple sources of information and every organisation has a different knowledge base. The service will involve several levels including a National Library for Oral Health , generation of evidence based pathways and a NHS Care Record Service.
By 2011 patients will be responsible for their own medical records, know their NHS number, receive quality assured knowledge and enter data before consultations, use a decision aid before making the decision to have an operation, know they are on a care pathway and accept medical knowledge is of a variable quality.

Implementation of the research evidence - Jan Clarkson (Dental Health Services Research Unit, University of Dundee, UK)

Implementation is the scientific study of methods to promote the uptake of research findings and hence to reduce inappropriate care. The aim of the ERUPT trial in Scotland was to determine if fees plus education in evidence based healthcare is more effective in improving dentist's implementation of research evidence (findings from the Cochrane fissure sealant review) than either strategy alone. The clinical outcomes were the use of a preventative fissure sealant (PFS) and the appropriate use of a preventative fissure sealant (APFS). The payment of a fee had a significant effect on PFS placement but not on APFS. Education had no effect on PFS or APFS. Methods for implementing research evidence were discussed. VDP trial. Following the publication of the Cochrane scale and polish review, an MRC application has been submitted to undertake a trial to determine if routine S&P, or oral health advice or both leads to cost effective improvements in periodontal health and patient self care. Unfortunately the application was declined due to the change in contact in England.

Break out sessions:
Barriers to dissemination/implementation:

How will healthcare service changes and agenda changes effect dissemination (highlighting the differences within countries)?

Barriers
Misinformation published by the press and other sources of subjective information.
Access to credible, easy to use sources on information for practitioners.
Resistance to change by professionals and they tend to follow.
Lack of evidence and the evidence that exists is not understood.
Science is not part or driver of dental culture.
Poor dental education (undergraduate and postgradutate).
Poor organisation and commitment to marketing.

Opportunities
Organised marketing programs (information, guidelines etc), use knowledge brokers (key professionals to communicate the science message).
Involve practitioners in promoting science and change the environment for dentistry (improve dental education, licensing, decisions).
Patient information and develop their knowledge.
Accept and embrace uncertainty.
Use behavioural change strategies e.g. electronic reminders in management systems.
Integrate with other agencies (purchasing, licensing, third party) and healthcare providers.
Formation of strategic alliances e.g. Cochrane EPOC Group.

Virtual Centre for Improving Oral Health - Nigel Pitts (Dental Health Services Research Unit, University of Dundee, UK)

A UK-based Network to advance effective oral health policy and practice. Its aims are 1) to ensure information is made readily accessible in a variety of formats; 2) identify and objectively synthesise quality assured best evidence that is relevant to the NHS, its staff and patients; 3) develop methods to package research knowledge for effective dissemination and implementation; and 4) inform NHS dental policy, service and education interests on EBD issues.

Action plan
The Virtual Centre for Improving Oral Health can become a voice for the dental professionals and the public, providing the latest information in a variety of formats.
Involve all decision making organisations.
Dental education - consider how to engage then in the Virtual Centre and provide services to faculty and staff.
EBD assessment modules with CE credits could be provided.